Symptomatic relapse and long-term sequelae of COVID-19 in a
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A previously healthy 30-year-old man with no significant medical history developed substernal chest pain 2 days after an international flight on 15 March 2020. He experienced this burning localized chest pain for 2 days before developing night sweats and fever to 100.1°F. On 19 March 2020, he was tested for SARS-CoV-2 via nasopharyngeal swab, which was positive for viral nucleic acid. At this time, his wife also had chest pain and went on to develop nausea and vomiting along with his 3-year-old son who also had gastrointestinal symptoms, but they were never tested for COVID-19. He is a life-long non-smoker and consumes 1–2 drinks of alcohol per month.

Thirty-two days after his presumed exposure and 30 days after his initial symptoms, he began developing chest discomfort again on 17 April 2020. After 2 days of persistent symptoms, he presented to the emergency department (ED) once more where he was found to be positive for SARS-CoV-2 again, exactly 31 days after his first positive test. A chest X-ray was done at this time which showed no signs of active disease in the lungs. He was given a 5-day course of azithromycin and instructed to quarantine until his symptoms resolved.

For the next 7 days, he continued to have diffuse chest discomfort with dyspnoea and fatigue for which he represented to the ED on 26 April 20. Vital signs were within normal limits. His labs showed a mild leucocytosis, elevated neutrophil count, mildly depressed lymphocyte count, haemoglobin approaching the upper limits of normal (160 g/L) with mildly low red cell distribution width (10.8%), platelet count near the lower limit of normal, as well as normal electrolytes, liver function tests, renal function tests, D-dimer, troponin-T and BNP NT-Pro. His EKG was normal and a chest X-ray showed no acute abnormalities, including no evidence of pulmonary edema. He also had a chest CT PE protocol which showed some subsegmental atelectasis but was negative for pulmonary embolus. He was again discharged to home and told to continue quarantining until he felt well for 72 consecutive hours. His symptoms persisted for another 8 days but began improving again 17 days after they began, 50 days after his initial exposure. We are not aware of any individuals who were infected by this patient during his first or second bout of symptoms.

In summary, this patient experienced two bouts of COVID-19 symptoms with positive SARS-CoV-2 testing results at the beginning of both bouts. The patient experienced worsening overall health as assessed by the EQ5D Visual Analogue Scale Symptom Scale during both of these bouts with complete resolution of all functioning in between. At the time of publication, the patient continues to report burning chest pain, dyspnoea, and fatigue and feels he has not returned to his baseline state of health 8 months following the initial infection. He was recently diagnosed with intercostal neuralgia for which he is receiving nerve blocks. The patient had IgG and IgM testing performed in June 2020, which found no IgG or IgM antibodies.