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Letter to the Editor
Reinfection by SARS-CoV-2: The first one in a family reported in Spain
Reinfección por SARS-CoV-2: primer caso en una familia referido en España
Antonio L. Aguilar-Sheaa,b,
Corresponding author
, Joaquín Gutiérrez-Martín-Arroyoa, Miguel Vacas-Córdobac, Cristina Gallardo-Mayod
a Centro de Salud Puerta de Madrid, Atención Primaria de Madrid, Spain
b Hospital Clinical Multiprofesional COVID19 Unit, Universitary Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
c Internal Medicine Department, Universitary Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
d Anesthesiology and Reanimation Department, Universitary Hospital Infanta Leonor, Madrid, Spain
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by a positive reverse-transcription polymerase chain reaction &#40;RT-PCR&#41; test from a oropharyngeal sample and a negative nasopharyngeal RT-PCR test 14 days later&#46; At the time he described 2 days of sore throat&#44; followed by fever up to 38&#46;8<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; general malaise and nasal congestion for 3 days&#44; exertional tachycardia and chest pain for 2 days and loss of smell and taste for about one month&#46; Symptomatic treatment was given with acetaminophen for 5 days as needed&#46; He experienced a full recovery and went back to normal life activities&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">By mid-April 2020 the family was tested with rapid antibody tests&#46; The wife&#44; 4-year-girl and 6-year-boy were negative&#44; the FP&#44; the father&#44; was positive with IgM and IgG lines and surprisingly the 8-year-old boy was positive with no IgM line and a strong IgG line&#46; It was suspected that the child&#39;s symptoms from February were actually caused by coronavirus&#44; since no other infectious disease was reported&#44; and it coincided with the suspicion that coronavirus was already in circulation in Spain at the time&#46; In August 2020 the blood test was done to FP&#44; Immunoglobulin &#40;Ig&#41;G antibody for SARS-CoV-2 was positive 6&#46;4 &#40;&#60;1&#46;6&#41;&#44; no IgM was reported&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Time passed and both physicians kept working and then&#44; in the beginning of January 2021&#44; with the 3<span class="elsevierStyleSup">rd</span> national and world COVID-19 wave&#44; the healthy 39-year-old Anaesthetist&#44; presented with a mild odynophagia that was followed the next day by general myalgias&#44; feverish sensation with a temperature of 36&#46;4<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; slight general discomfort and nasal congestion&#46; Antigen rapid test was done with a positive result with in the first 2<span class="elsevierStyleHsp" style=""></span>min with a strong positive line&#46; Isolation from the rest of the family members was hard to follow and apparently the husband and the 8-year-old boy were immune&#46; Over the next 2 days&#44; she suffered a slight headache&#44; myalgias and general malaise&#46; She then associated loss of taste and smell and for 2 days she complained of intense triceps and external thigh area muscle pain that resolved in 2 days&#46; At day 7 antigen test was repeated&#44; being still positive&#44; taking longer to give the result and with a less intense line&#46; No fever&#44; cough&#44; dyspnoea or chest pain were ever reported&#46; Symptoms progressively resolved with persistence of loss of smell and taste&#46; At day 11 the antigen test was repeated and found negative&#46; She received symptomatic treatment with acetaminophen which she took occasionally&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two days later after the wife&#39;s initial symptoms&#44; the husband described an uncomfortable night sleep and waking up with a sore throat&#44; that morning the rapid antigen test was negative&#46; The next day a blood test to review SARS-CoV-2 immunity was done revealing positive IgG antibodies 29&#46;30 &#40;&#60;9&#41;&#46; The sore throat persisted&#44; with slight general malaise&#44; nasal congestion and some nasal discharge&#46; The following day&#44; day 3&#44; due to symptoms persistence&#44; a second rapid antigen test was done with a light positive result&#44; not with in the first 5<span class="elsevierStyleHsp" style=""></span>min&#46; Tiredness&#44; malaise&#44; nasal congestion and discharge persisted&#44; with no fever or cough over the next days&#46; Symptoms were described as the usual for a cold&#46; Another 2 days passed&#44; rapid antigen test was repeated with a fast strong positive result&#44; that day nasopharyngeal RT-PCR test was done and was found to be POSITIVE&#44; cycle threshold &#40;ct&#41; value of RdRp gene &#60;20&#44; that corresponds with a high viral load&#46; Reinfection was confirmed&#46; A new antigen test was done 3 days later with another slow light positive result&#46; Finally&#44; at the 10<span class="elsevierStyleSup">th</span> day&#44; rapid antigen test was again done with a negative result&#46; 2 days later&#44; RT-PCR was repeated &#40;a week after the previous one&#41; result still came POSITIVE with a ct of 34&#46; Symptoms progressively resolved within a week&#44; but a funny intermittent smell appeared&#44; with no loss of smell or taste&#44; which resolved in 10 days&#46; RT-PCR was again repeated one week apart&#44; being the test negative&#46; A week later&#44; IgG for SARS-CoV-2 was again reported positive&#46; He was negative for HIV&#44; and showed no biological evidence of immunodeficiency&#46; Genomic analysis of SARS-CoV-2 extracted from the nasopharyngeal PCR swabs from the reinfection revealed 20I&#47;501Y&#46;V1&#44; Britain variant B&#46;1&#46;1&#46;7&#46; This variant was not reported during the first wave in Spain so genetically differences between each infection was concluded&#44; confirming the reinfection by different variants&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the 7<span class="elsevierStyleSup">th</span> day of the mother&#39;s symptoms and 4<span class="elsevierStyleSup">th</span> day of the initial symptoms of the father&#44; rapid antigen test was done on the 3 asymptomatic children being all 3 negative&#46; A week later it was repeated&#44; being also negative&#46; The 3 children did not show any symptoms&#44; except for the 6 year-old-boy that complained of nasal congestion for 2 days that did not require any treatment and who did not suffer any loss of energy&#46; 2 days later the previously described antigen test was done on all 3 children&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two weeks later the rapid total antibody tests were done on all 5 family members&#58; mother and father were positive&#44; the 8 year-old boy and the 4 year-old girl were negative and the 6 year-old-boy was POSITIVE&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All family members experienced a full recovery and progressively reassumed their daily routines &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In late 2019&#44; a cluster of pneumonia cases in Wuhan City&#44; capital of Hubei in China&#44; were identified to be caused by a novel betacoronavirus&#44; and the disease was named Coronavirus disease 2019 &#40;COVID-19&#41;&#46; After the genetic sequence of the virus&#44; the International Committee on Taxonomy of Viruses named it severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41;&#46; Coronaviruses are not unknown to humanity&#44; four of these &#40;HCoV-NL63&#44; HCoV-229E&#44; HCoV-OC43 and HKU1&#41; currently cause mild common cold symptoms and another two&#44; now extinct&#44; caused epidemics&#44; severe acute respiratory syndrome coronavirus &#40;SARS-CoV&#41; in 2002&#8211;2003 and Middle East respiratory syndrome coronavirus &#40;MERS-CoV&#41; in 2012&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Coronavirus disease 2019 &#40;COVID-19&#41; pandemic has become the greatest health challenge worldwide of the last century&#46; Clinical presentation of Coronavirus disease 2019 &#40;COVID-19&#41; is highly variable and ranges from asymptomatic to severe pneumonia and acute respiratory distress syndrome requiring intensive care&#46; In this case the children&#39;s symptoms were much lighter that the adults and varied among each age group&#46; This milder presentation in children can be explained by the quality and&#47;or quantity difference in the virus cell receptor &#40;ACE2 protein&#41;&#44; a greater population of na&#239;ve T-cells and some cross protection from antibodies from past infections of other coronavirus&#44; with more incidence during the early years of life&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Since the beginning of the infections&#44; there has always been a concern about the possibility of reinfections&#46; Coronaviruses are considered stable viruses that limit mutation&#44; errors in RNA sequence&#44; due to a &#8220;correcting&#8221; enzyme&#46; Data suggest that overall&#44; the short-term risk of reinfection appears low&#44; a study of UK health-care workers showed that reinfection with SARS-CoV-2 is uncommon up to 6 months after the primary infection&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To analyse the available data on reinfection a search in Medline&#40;Pubmed&#41; was done on March 1<span class="elsevierStyleSup">st</span> 2021 using keywords &#8220;COVID19&#8221;&#44; &#8220;SARS-CoV-2&#8221;and &#8220;reinfection&#8221;&#46; Reinfections are being described related with different viral strains&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a> so even though the virus is stable it still has the capacity to mutate and avoid the immune system&#46; Sequencing that demonstrates a different strain at the time of presumptive reinfection is necessary to make the distinction&#46; Different viral strains have been described in Europe&#44; South Africa&#44; United Kingdom and Brasil &#40;20E-EU1&#44; B&#46;1&#46;1&#46;7 501YV1 VOC 202012&#47;01&#44; B&#46;1&#46;351 501Y&#46;V2 and B1&#46;1&#46;28&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> revealing the capability of the virus of a natural selection trough bottle necks and founder effects increasing its transmissibility&#46; In most of the cases the second infection was less symptomatic than the initial one&#44; raising the possibility that immunity from an initial infection might attenuate the severity of a reinfection even if it does not prevent it&#46; In this case&#44; the husband&#39;s reinfection was much milder that the initial infection&#44; being the second one described as a normal cold&#46; Recent research conducted by Tarke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> indicates that variants are unlikely to escape T cell immunity&#44; in the line that previous infection or vaccination will give protection even if the virus mutates&#46; No Spanish cases were found in the literature&#44; being the first published case in Spain&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Ongoing cases of COVID-19 and the vaccination programmes all over the world will hopefully lead to quicker herd immunity and will stop putting in jeopardy all the health care systems all over the world&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although the virus is quite stable&#44; it has had access to so many people and has replicated in a virgin human community so the capability of mutations is at its peak&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Reinfection with SARS-CoV-2 is a possibility&#44; this case explains that infections do not provide long-term immunity and that the virus has the ability to mutate and avoid the immune system&#46; We consider that by adding the number of those recovered from the natural infection to those vaccinated&#44; we will have increased the number of humans that have been in contact the virus&#46; The re-exposure to different virus strains will happen&#44; since the mutations capability of the virus has been proven&#46; The immunity generated from the vaccination or natural infection should be able to recognise different virus strains&#44; providing sufficient protection for milder forms of COVID-19&#44; such as the case reported&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Is the virus here to stay&#63; Will it become another common cold virus like HCoV-NL63&#44; HCoV-229E&#44; HCoV-OC43 and HKU1&#63; Answers to these questions will be known in the coming months&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">External funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos