SCIENCE CHINA

Life Sciences
•RESEARCH PAPER• March 2020 Vol.63 No.3: 364–374
https://doi.org/10.1007/s11427-020-1643-8

Clinical and biochemical indexes from 2019-nCoV infected patients

linked to viral loads and lung injury
1†* 1† 2,3† 3† 1 1
Yingxia Liu , Yang Yang , Cong Zhang , Fengming Huang , Fuxiang Wang , Jing Yuan ,
1 1 1 1 1 1
Zhaoqin Wang , Jinxiu Li , Jianming Li , Cheng Feng , Zheng Zhang , Lifei Wang ,
1 1 3 3 4 5 5
Ling Peng , Li Chen , Yuhao Qin , Dandan Zhao , Shuguang Tan , Lu Yin , Jun Xu ,
2 3* 1*
Congzhao Zhou , Chengyu Jiang & Lei Liu
1
Shenzhen Key Laboratory of Pathogen and Immunity, National Clinical Research Center for Infectious Disease, State Key Discipline of
Infectious Disease, Shenzhen Third People’s Hospital, Second Hospital Affiliated to Southern University of Science and Technology, Shenzhen
518112, China;
2
Hefei National Laboratory for Physical Sciences at the Microscale and School of Life Sciences, University of Science and Technology of
China, Hefei 230027, China;
3
State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Department
of Biochemistry, Peking Union Medical College, Beijing 100005, China;
4
Institute of Microbiology, Chinese Academy of Sciences, Beijing 100101, China;
5
Emergence Department Peking Union Medical College Hospital, Beijing 100731, China

Received February 5, 2020; accepted February 8, 2020; published online February 9, 2020

The outbreak of the 2019-nCoV infection began in December 2019 in Wuhan, Hubei province, and rapidly spread to many
provinces in China as well as other countries. Here we report the epidemiological, clinical, laboratory, and radiological char-
acteristics, as well as potential biomarkers for predicting disease severity in 2019-nCoV-infected patients in Shenzhen, China.
All 12 cases of the 2019-nCoV-infected patients developed pneumonia and half of them developed acute respiratory distress
syndrome (ARDS). The most common laboratory abnormalities were hypoalbuminemia, lymphopenia, decreased percentage of
lymphocytes (LYM) and neutrophils (NEU), elevated C-reactive protein (CRP) and lactate dehydrogenase (LDH), and decreased
CD8 count. The viral load of 2019-nCoV detected from patient respiratory tracts was positively linked to lung disease severity.
ALB, LYM, LYM (%), LDH, NEU (%), and CRP were highly correlated to the acute lung injury. Age, viral load, lung injury
score, and blood biochemistry indexes, albumin (ALB), CRP, LDH, LYM (%), LYM, and NEU (%), may be predictors of disease
severity. Moreover, the Angiotensin II level in the plasma sample from 2019-nCoV infected patients was markedly elevated and
linearly associated to viral load and lung injury. Our results suggest a number of potential diagnosis biomarkers and angiotensin
receptor blocker (ARB) drugs for potential repurposing treatment of 2019-nCoV infection.
2019-nCoV, Angiotensin II, ARDS

Citation: Liu, Y., Yang, Y., Zhang, C., Huang, F., Wang, F., Yuan, J., Wang, Z., Li, J., Li, J., Feng, C., et al. (2020). Clinical and biochemical indexes from 2019-
nCoV infected patients linked to viral loads and lung injury. Sci China Life Sci 63, 364–374. https://doi.org/10.1007/s11427-020-1643-8

†Contributed equally to this work

*Corresponding authors (Lei Liu, email: [email protected]; Chengyu Jiang, email: [email protected]; Yingxia Liu, email: [email protected])

© Science China Press and Springer-Verlag GmbH Germany, part of Springer Nature 2020 life.scichina.com link.springer.com
 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3 365

INTRODUCTION family stayed in a hotel at a distance of about 2.5 miles away

from Huanan Seafood Market for 6 days. On Dec 31, 2019
In December 2019, a cluster of pneumonia cases linked to the and Jan 1, 2020, they went to two local households for
Wuhan seafood wholesale market were reported and found to dinner. Cases 1, 2, and 6 developed fever on Jan 1, 2020, and
be caused by 2019 novel coronavirus (2019-nCoV), the se- case 6 also developed diarrhea. On Jan 4, 2020, they returned
venth member of the coronavirus family that infects humans to Shenzhen city (Figure 1) where they lived with case 5,
(Huang et al., 2020; Li et al., 2020; Tan, 2020). A possible who subsequently developed fever, cough, and myalgia on
person-to-person spread was identified when a cluster of Jan 8, 2020. Of note, none of the family members had an
2019-nCoV patients with Wuhan traveling records emerged exposure history to indicate direct contact with seafood, live
in more cities in China (Li et al., 2020; Huang et al., 2020). poultry, or other wild animals. Cases 10 and 11 were a couple
By Feb 2 of 2020, 11,901 cases were laboratory confirmed who lived about 5.5 miles away from Huanan Seafood
and 259 died (National Health Commission Update on Market. They developed symptoms with fever and cough on
February 02, 2020, http://www.nhc.gov.cn/xcs/yqfkdt/ Jan 4, 2020, and went to Shenzhen on Jan 13, 2020 (Figure
202002/d5c495da742f4739b7f99339c3bd032f.shtml). All 1). According to the possible exposure histories of the 12
patients had the novel coronavirus pneumonia (NCP). The patients, the estimated incubation period ranged from 1 to 13
novel coronavirus belongs to lineage B of the genus beta- days. Most of the cases developed influenza-like symptoms,
coronavirus of the Coronavirus family, which includes and the intervals between illness onset and admission were
SARS-CoV and MERS-CoV (Zhu et al., 2020). The 2019- between 5 and 16 days (Table 1). Six (50%) cases had un-
nCoV is the seventh member of the coronavirus family to derlying diseases, including chronic heart disease, renal
infect humans (Chan et al., 2020). A recent study reported diseases, and diabetes. Pneumonia was the most common
that fever, cough, myalgia or fatigue were common symp- applications, followed by acute respiratory distress syn-
toms, and sputum production, headache, haemoptysis, and drome (ARDS) (including two cases with severe ARDS). All
diarrhea were less common symptoms (Huang et al., 2020). the patients received anti-viral (Ribavirin and Interferon)
All patients had pneumonia and about half developed dys- treatments, and six of them required mechanical ventilation,
pnea. One third of the patients were admitted to ICU (Huang among whom cases 2, 4, and 10 received invasive mechan-
et al., 2020). Compared with the 10% fatal rate of SARS- ical ventilation. Corticosteroids and immunoglobulin were
CoV (Jiang et al., 2005) and 37% fatal rate of MERS-CoV also used in cases 2, 4, and 10 (Table 1).
(Niu et al., 2018), 2019-nCoV is now the third lethal virus in The complete blood count and blood biochemistry were
the coronavirus family. measured for each patient either on the date of hospital ad-
Our study describes the clinical characteristics of 12 2019- mission, or at the earliest time-point thereafter. The most
nCoV infected patients. All patients were admitted to the common laboratory abnormalities noted were hypoalbumi-
Shenzhen Third People’s Hospital, China. Clinical char- nemia, lymphopenia, decreased percentage of lymphocytes
acteristics and blood biochemical indexes of 2019-nCoV (LYM) and neutrophils (NEU), elevated C-reactive protein
patients were recorded and examined at the hospital. Patient (CRP) and lactate dehydrogenase (LDH), and decreased
respiratory samples, including throat swabs and bronch- CD8 count (Table 2). The chest computed tomography (CT)
oalveoar lavage fluid (BALF), were collected and real-time scans of all patients showed ground-glass opacity around the
PCR was used to confirm 2019-nCoV infection. We identi- shadow and pleural effusion, especially the lower and per-
fied potential biomarkers of disease severity. Our results ipheral parts of the lungs (Figure 2; Figure S1 in Supporting
should help physicians to diagnose and treat patients infected Information). During the progression of the disease, the
with 2019-nCoV. density of ground-glass opacity increased, and the range
became larger, diffusing to the center and finally throughout
the lungs (Figure 2). Case 4 developed fulminant myocarditis
RESULTS 5 days after illness onset. The biochemistry indexes asso-
ciated with the function of heart, i.e., creatine kinase (CK),
Twelve patients (four females and eight males) were ad- myoglobin (MYO), cardiac troponin 1 (Ctn1), brain na-
mitted to Shenzhen Third People’s hospital and confirmed to triuretic peptide (BNP), and CK myocardial band (CK-MB),
be infected with 2019-nCoV by Guangdong Center for were significantly elevated in case 4 (Table 2), and ultrasonic
Disease Control and Prevention (CDC) as of Jan 21, 2020. cardiogram results showed that the left ventricular ejection
Of these patients, seven patients were over 60 years old. fraction (LVEF) was 32%, and the left ventricular diameter
Notably, one adolescent case (case 7, 10 years old) was also (LV) was 61 mm on Jan 15, 2020 (5 days after illness onset)
found. Except for case 5 who lived in Shenzhen, 11 cases (Figure S2 in Supporting Information).
(91.7%) lived or traveled to Wuhan city, and two family We used the Spearman correlation coefficient to calculate
clusters were identified. Cases 1, 2, 6, and 7 within one the correlation between 2019-nCoV virus cycle threshold
366 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3

Figure 1 A timeline of events in human cases with 2019-nCoV. Patients are ordered in chronological order based on the date of admission to our hospital.
Various milestones in the disease course are indicated with different graphics. Patients within a family were marked in red and blue, respectively.

(Ct) value, which is reciprocal to virus load, with clinical (Figure 3B).
disease severity scores, Acute Physiology and Chronic Among the eight blood biochemistry indexes distinguished
Health Evaluation (APACHE) II Score, partial pressure of in blood samples of 2019-nCoV infected patients, specifi-
arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) cally ALB, creatinine (CRE), LYM, LYM (%), NEU (%),
ratios, and Murray scores of infected patients (Figure 3A; LDH, CRP, and CD8, we found ALB, LYM, LYM (%), NEU
Figure S3 and Table S1 in Supporting Information). The viral (%), LDH, and CRP were highly linked to lung injury
load of 2019-nCoV detected from patients highly correlated Murray score (Figure 4). Previous studies reported that hy-
with both ARDS index PaO2/FiO2 ratio and lung injury poalbuminemia is a potent, dose-dependent predictor of poor
Murray score, but not with multiple organ dysfunction syn- outcome (Vincent et al., 2003). Therefore, albumin therapy
drome (MODS) score APACHE II (Figure 3A; Figure S3 in might be a potential remedy for NCP.
Supporting Information). This finding is consistent with the We next statistically analyzed the link between the clinical
clinical features in this report that half of the infected patients and biochemical characteristics and disease severity, the
developed ARDS and all patients were diagnosed with definition of which is described in the second edition of
pneumonia, indicating that lung failure of the infected pa- medical guidelines of 2019-nCoV infection from the Na-
tients is the major dysfunction caused by 2019-nCoV in- tional Health Commission of the People’s Republic of China.
fection. Using the Spearman method, we further correlated We calculated the area under the curve (AUC) of the receiver
the Ct value (viral load) of the 2019-nCoV virus with bio- operating characteristics (ROC) curve for characteristics
chemical and clinical indexes, and found that the levels of from 2019-nCoV infected patients. The AUC value of the
infectious diseases indicators albumin (ALB), and percen- ROC curve of age was 1, i.e., age could fully predict the
tage of immunological cells of LYM, and NEU were sig- disease severity of 2019-nCoV infected patients (Figure 5).
nificantly correlated with infected 2019-nCoV viral load The youngest “severe” patient in this Shenzhen cluster aged
 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3 367

a)
Table 1 Epidemiological and clinical features of human subjects hospitalized with 2019-nCoV infection
Characteristics Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Case 11 Case 12
Age 65 66 62 63 63 36 10 35 51 65 72 56
Sex Female Male Male Male Female Male Male Male Male Female Male Female
Onset to admission (days) 9 8 4 5 8 5 5 7 13 16 16 7
Initial symptoms 　 　 　 　 　 　 　 　 　 　 　 　
Fever Yes Yes Yes Yes Yes Yes　 No　 Yes No　 Yes Yes Yes
Cough Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes
Headache No No No No No No No No No No No No
Myalgia Yes Yes No No Yes No No No Yes No No No
Chill Yes Yes Yes No Yes No No No Yes No No No
Nausea or vomiting No Yes No No No Yes No No No No No No
Diarrhea No No Yes No No Yes No No No No No No
Underlying diseases 　 　 　 　 　 　 　 　 　 　 　 　
Chronic heart disease Yes Yes Yes No No No No No No No Yes No
Chronic lung disease No No No Yes No No No No No No No No
Chronic renal disease No No Yes No No No No No No No Yes No
Chronic liver disease No No No No No　 No No No No No No No
Diabetes No No No No No No No No No Yes No Yes
Hypertension Yes Yes No No No No No No No No Yes No
Cancer No No No No No No No No No No No No
Bacterial co-infections No Yes No Yes No No No No No No No No
Complications 　 　 　 　 　 　 　 　 　 　 　 　
Pneumonia Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
ARDS Yes Yes Yes Yes Yes No No No No Yes No No
Severe ARDS No Yes No Yes No No No No No No No No
Respiratory failure No Yes No Yes No No No No No Yes No No
Hepatic insufficiency No Yes No Yes No No No No No No No No
Renal insufficiency No Yes No Yes No No No No No No No No
Cardiac failure No No No Yes No No No No No No No No
Shock No No No Yes No No No No No No No No
Treatment 　 　 　 　 　 　 　 　 　 　 　 　
Oseltamivir Oseltamivir Oseltamivir Oseltamivir
Antiviral agents Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin Ribavirin
Interferon Interferon Interferon Interferon Interferon Interferon Interferon Interferon Interferon Interferon Interferon Interferon

Corticosteroid No Yes No Yes No No No No No Yes No No

Mechanical ventilation Yes Yes Yes Yes Yes No No No No Yes No No
Invasive mechanical ventilation No　 Yes No Yes No No No No No Yes No No
Immunoglobulin No Yes No　 Yes Yes No No No No Yes No No
a) Severe ARDS, PaO2/FiO2 <100.

56 years old. The amount of 2019-nCoV detected in patients’ receptor of SARS-CoV (Xu et al., 2020), which is a critical
respiratory tracts and measured conversely in Ct value, as enzyme in the renin-angiotensin system (RAS) (Huang et al.,
well as the lung injury Murray score and PaO2/FiO2 ratio, 2014; Zou et al., 2014). RAS plays important roles in
may very well predict the disease severity (Figure 5). Among maintaining blood pressure homeostasis (Forrester et al.,
the biochemical indexes, the AUC of ROC for the infection 2018), and salt and fluid balance (Lin et al., 2017). ACE and
and tissue damage indicators, ALB, CRP, and LDH were 1, ACE2 play different roles in RAS; ACE generates Angio-
0.938, and 0.844, respectively, and may also be potential tensin II, whereas ACE2 is a negative regulator of the sys-
predictors of disease severity. The AUCs for lymphocyte tem, decreasing Angiotensin II (Crackower et al. 2002). The
count and the percentage of lymphocytes and neutrophils abnormal increase of Angiotensin II was reported mostly
were 1, 0.844, and 0.812, respectively, and thus may also associated with hypertension and heart failures (Packer and
predict disease severity. McMurray, 2017), and sometimes also lung and renal dys-
A recent article studied the 2019-nCoV genome sequence functions (Fröhlich et al., 2016; Kuba et al., 2005; Zou et al.,
and predicted that the new coronavirus shared the ACE2 2014; Damman et al., 2018; Imai et al., 2005; Rai et al.,
368 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3

Figure 2 (Color online) Computed tomographic (CT) scans and chest radiographs of case 2. (A) CT scans and (B) chest radiographs of case 2 taken at
indicated date are shown. d.a.o, days after illness onset.

a)
Table 2 Clinical characteristics and laboratory results of subjects hospitalized with 2019-nCoV infection
Normal range Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Case 11 Case 12
PaO2/FiO2 400–500 131 96 159 65 256 438 469 561 420 126 249 386
9 –1
WBC (×10 L ) 3.5–9.5 4.31 5.24 3.85 6.79 6.71 13.55 6.72 4.62 4.94 5.89 4.99 3.98
LYM (%) 20–50 20.4 23.1 21.6 3.8 11.5 17.5 56.4 34.4 29.4 7.1 19.8 20.9
9 –1
LYM (×10 L ) 1.10–3.20 0.88 1.21 0.83 0.26 0.77 2.37 3.79 1.59 1.45 0.42 NA 0.83
NEU (%) 40–75 72.6 67.4 58.7 93 80.9 77.4 33.7 56.8 64.3 90.9 74.8 75.3
9 –1
NEU (×10 L ) 1.8–6.3 3.13 3.53 2.26 6.31 5.43 10.49 2.26 2.62 3.18 5.35 3.73 3
9 –1
PLT (×10 L ) 100–300 161 118 121 119 215 250 196 236 184 118 99 152
–1
AST (U L ) 0–45 26.7 33.6 26 107 26.2 29.3 34.7 28.9 37.7 52 42.1 36.1
–1
ALT (U L ) 0–45 26.6 26.5 26 62 45.3 30 32.8 22.4 39.5 15.7 29 23.6
–1
TB (µmol L ) 3.0–22 10.8 9.5 9.1 6.2 11.6 12 8.5 7.8 7.8 8.4 9.6 5.9
–1
ALB (g L ) 40.0–55.0 36.8 39.5 41.6 35.1 38.3 48.9 46.4 43.4 46.2 34.6 42.6 38.4
–1
CRE (µmol L ) 58–110 46.5 81.9 104 220 44.1 79.7 53 95.4 82.5 54.1 122 43.6
–1
BUN (mmol L ) 3.2–7.1 2.87 5.37 5.51 9.81 4.8 6.65 7.65 4.21 3.71 4.48 6.89 3.12
–1
CK (U L ) 50–310 46 118 97 876 NA 111 70 NA NA NA NA NA
–1
MYO (ng mL ) 0–110 25.2 38.66 50.1 390.97 32.7 35 18.7 20.5 27 40.1 111.9 23.7
–1
Ctnl (µg mL ) 0–0.1 0.012 0.012 0.012 11.37 0.012 0.012 0.012 0.012 0.012 0.014 0.012 0.012
–1
BNP (pmol L ) 0–23.1 4.32 5.7 3.78 161.99 NA NA NA NA NA NA NA NA
–1
CK-MB (ng mL ) 0–2.37 0.24 0.48 <0.22 20.53 <0.22 0.25 0.26 <0.22 <0.22 0.23 0.97 <0.22
–1
LDH (U L ) 114.0–240.0 662 593 169 720 696 491 475 558 476 1266 510 648
–1
CRP (mg L ) <10 52.6 38.6 52.95 89.94 53.6 5.8 5 35.6 13 33.2 85 28.4
–1
PCT (ng mL ) 0–0.5 0.048 0.04 0.095 9.18 0.031 <0.020 <0.020 0.029 <0.020 0.077 0.218 0.033
–1
CD4 (count μL ) 34–52 47.3 45.8 41.2 18.7 30.9 NA NA NA 50.2 34.9 50.7 43
–1
CD8 (count μL ) 21–39 16.7 16.5 11.6 10.9 23 NA NA NA 24.9 14.3 17 17.4
CD4/CD8 0.9–3.6 2.83 2.78 3.56 1.72 1.34 NA NA NA 2.02 2.45 2.98 2.47
a) NA, not available.
 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3 369

Figure 3 The Ct value of virus are highly correlated with clinical and laboratory manifestations in 2019-nCoV-infected patients. The Ct value of virus is
highly correlated with (A) PaO2/FiO2 ratio, Murray score and (B) CRP, ALB, LYM (%), LYM, NEU in 2019-nCoV-infected patients. The Ct value was
detected available in 10 patients with 2019-nCoV infection. PaO2/FiO2 ratio, Murray score, ALB, LYM (%), LYM, NEU, CRP, and LDH were detected from
12 2019-nCoV-infected patients. Spearman rank correlation analysis (r) and P values are provided in each graph.

2017; Torres et al., 2014). We measured the plasma level of infections. All patients were admitted to the Shenzhen Third
Angiotensin II from 2019-nCoV infected patients and heal- People’s Hospital, Shenzhen, China. All patients were either
thy individuals, the plasma levels of Angiotensin II from living in or traveling to Wuhan from late December of 2019
2019-nCoV infected patients were significantly higher than to early January of 2020, except case 5 who stayed in
that of healthy individuals (Figure 6A). Moreover, the level Shenzhen during the time period. Two family clusters were
of Angiotensin II in 2019-nCoV patients was strongly as- identified, and case 5 was in one of the family clusters with
sociated with viral load and lung injury (Figure 6B and C), cases 1, 2, 6, and 7. This secondary infection of case 5 is one
suggesting that the imbalanced renin-angiotensin system in evidence of possible person-to-person spread of 2019-nCoV.
patients was caused by 2019-nCoV and drugs of angiotensin- Cases 1, 2, 6, and 7 might have been simultaneously infected
converting enzyme inhibitor (ACEI) and angiotensin re- in Wuhan, probably by a super-spreader contacting them in
ceptor blocker (ARB) balancing RAS may be used re- the hotel or home of their relatives, as five of their relatives in
purposing on 2019-nCoV infected patients. Wuhan developed similar symptoms (Chan et al., 2020).
Since case 5 had disease onset 4 days after family members
returning from Wuhan, the latency of 2019-nCoV might be
DISCUSSION as short as 1–4 days while the latency of most other patients
was from 7 to 13 days (Figure 1). Two out of the 12 patients
We report 12 cases with laboratory confirmed 2019-nCoV had no diagnosis of fever, including case 7 who had a clinical
370 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3

Figure 4 The Murray score is highly correlated with laboratory manifestations in 2019-nCoV-infected patients. The Murray score is highly correlated with
ALB, LYM, LDH, LYM (%), NEU (%), and CRP. Murray score, ALB, LYM, LDH, LYM (%), NEU (%), and CRP were detected from 12 2019-nCoV-
infected patients. Spearman rank correlation analysis (r) and P values are provided in each graph.

image check when accompanying family members to the with the Murray scores in patients with 2019-nCoV (Figure
hospital (Table 1). The risk of virus spread increased with 4). The Murray score was originally developed to assess the
non-fever patients, indicating that it is important to establish severity of acute lung injury in ARDS (Murray et al., 1988),
epidemiological history during clinical reception of the pa- and higher scores indicate greater severity in ARDS patients.
tients. This is consistent with previous studies showing that hy-
–1
All samples from the respiratory tract, including throat poalbuminemia, lymphopenia, and CRP ≥4 mg dL were
swabs and BALF, were collected from 10 patients. Com- the predictive factors for pneumonia progression to re-
paring the laboratory tests of these samples, the results of spiratory failure in MERS-CoV infected patients and ele-
throat swabs and BALF collected at the same time from case vated lactate dehydrogenase was found with severe acute
1, 3, and 4 were not consistent (Table S1 in Supporting In- respiratory syndrome (SARS-CoV) infection on hospital
formation), i.e., positive in BALF and negative in throat admission (Ko et al., 2016; Liu et al., 2004; Leem et al.,
swabs, indicating that BALF was a more reliable sample for 2018). Therefore, the combinations of the hypoalbuminemia,
the 2019-nCoV test. It is worth noting that the laboratory test lymphopenia, and high concentrations of CRP and LDH in
of BALF from case 8 was negative, but positive with throat 2019-nCoV infected patients upon hospital admission may
swabs. Case 8 was discharged from our hospital after one predict more severe acute lung injury.
week. Further studies are necessary to elucidate whether the We discovered the markedly increased level of Angio-
foundation of disease was related to the location of the virus tensin II in the plasma samples from 2019-nCoV infected
in the respiratory tract. patients. Our previous mice study has demonstrated that
We found that the viral load was crucial in determining the SARS-CoV could bind to its receptor ACE2, down-reg-
disease severity, especially strongly correlated with lung ulating its expressions, resulting in increased Angiotensin II
injury Murray score (Figure 3A). Notably, the viral load from level in mouse blood samples, signaling through angiotensin
case 4 was very high when fulminant myocarditis also oc- II receptor 1, and induced acute lung injury (Huang et al.,
curred (Table 2 and Figure 3). This high viral load lasted for 2014; Imai et al., 2005; Zou et al., 2014). We have also
one week, indicating that the early detection of high viral reported that avian influenza A virus H5N1 infected mice
load may be associated with a high risk of fulminant myo- exhibited the acute lung injury through dysregulating RAS,
carditis. and markedly elevation of Angiotensin II level in H7N9
Our study provides a list of potential predictors for disease infected patients was associated with the disease severity and
severity. For example, our study demonstrated that ALB and outcomes (Guo et al., 2015; Huang et al., 2014). In addition,
LYM counts were negatively correlated with the Murray a retrospective cohort study in Texas, USA with hospitalized
scores, while CRP and LDH levels were positively correlated pneumonia patients reported that prior and inpatients use of
 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3 371

Figure 5 (Color online) Receiver operating characteristic (ROC) curve of clinical and biochemical indicators of 2019-nCoV-infected patients. (A) ROC
curve of the age, Murray score, Ct value of 2019-nCoV, PaO2/FiO2 ratio and (B) ROC curve of the ALB, LYM, CRP, LYM (%), LDH and NEU (%) were
calculated between four mild 2019-nCov-infected patients and eight severe 2019-nCov-infected patients. Detailed information is shown in Tables 1 and 2.

Figure 6 (Color online) Plasma angiotensin II levels are increased in 2019-nCoV-infected patients and correlated with viral Ct value and PaO2/FiO2 ratio.
(A) Box plot of angiotensin II levels in plasma of healthy controls (n=8) and 2019-nCov-infected patients (n=12). ***, P<0.001 (Mann-Whiney U test). The
correlation analysis between plasma angiotensin II levels and (B) viral Ct value, or (C) PaO2/FiO2 ratio of patients with 2019-nCoV infection. The viral titers
were detected available in 10 patients with 2019-nCoV infection. The PaO2/FiO2 ratio was detected from 12 2019-nCoV-infected patients. Spearman rank
correlation analysis (r) and P values are provided in each graph.

ACE inhibitor and ARB were associated with the decreased demonstrated that ARB drugs, especially losartan, could
mortality (Mortensen et al., 2012). Our previous studies effectively ameliorate mice acute lung injury induced by
372 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3

SARS-CoV and H5N1 influenza virus A (Kuba et al., 2005; chinacdc.cn/kyjz/202001/t20200121_211337.html?from=ti-

Yan et al., 2015). These data suggest that ARB drugs may be meline&isappinstalled=0), using a commercial kit specific
used as treatment for ICU patients infected with 2019-nCoV. for 2019-nCoV detection (GeneoDX Co., Ltd., Shanghai,
The number of laboratory test confirmed patients is rapidly China). The specimens were considered positive if the Ct
increasing. We hope that this report of the 12 cases in value was ≤37.0, and negative if the results were un-
Shenzhen could provide useful information to prepare for determined. Specimens with a Ct higher than 37 were re-
potential pandemics of NCP. peated. The specimen was considered positive if the repeat
results were the same as the initial result and between 37 and
40. If the repeat Ct was undetectable, the specimen was
METHODS considered negative.
Patients
Quantification of hypoxia and lung injury
Twelve patients with pneumonia of unknown cause were
admitted to the Shenzhen Third People’s Hospital in Quantification of hypoxia and lung injury were carried out as
Shenzhen, China between Jan 11 and Jan 20, 2020, and were previously reported (Bi et al., 2019; Yang et al., 2019). In
confirmed to be infected with 2019-nCoV by Guangdong brief, the partial pressure of oxygen (PaO2) in arterial blood
CDC (Center for Disease Control and Prevention). The age taken from the patients at various time points after hospita-
of the patient ranged between 10 and 72 years old. Of the 12 lization was measured by the ABL90 blood gas analyzer
patients, three patients were in a critical condition and five (Radiometer). The fraction of inspired oxygen (FiO2) was
were classified as severe, according to the guidelines of calculated by the following formula: FiO2=(21+oxygen flow
2019-nCoV infection from the National Health Commission –1
(in units of L min )×4)/100. The PaO2/FiO2 ratio (in units of
of the People’s Republic of China. Bronchoalveolar lavage mmHg) was calculated by dividing the PaO2 value with the
fluid (BALF) and throat swabs samples of 2019-nCoV in- FiO2 value. A PaO2/FiO2 ratio less than or equal to
fected patients were collected to detect virus titers. Blood 100 mmHg is considered one of the criteria for ARDS.
samples from 2019-nCoV infected patients and healthy in-
dividuals working at Shenzhen Third People’s Hospital were
Plasma angiotensin II measurement
collected for measurement of plasma angiotensin II levels.
The study was performed in accordance with guidelines The plasma samples from 12 2019-nCoV infected patients
approved by the Ethics Committees from Shenzhen Third were separated from blood samples in BSL-3 laboratory. The
People’s Hospital (SZTHEC2016001), and verbal informed concentrations of plasma angiotensin II were measured by
consents were obtained from all patients or patients’ family ELISA assay following the manufacturer’s instructions
members. (Cloud-clone, TX, USA).

Data collection and analysis of clinical findings Statistical analysis

Clinical information, including complete blood counts, blood We used the Mann-Whitney U test to compare between two
biochemistry, chest radiographs, and computed tomographic groups with continuous variables. The Spearman rank cor-
(CT) scans from 12 patients with laboratory-confirmed in- relation coefficient was used for linear correlation analysis
fection of 2019-nCoV were collected at the earliest time between two groups with continuous variables. ROC curves
points possible upon hospitalization. were calculated with AUC estimation for predictive analysis.
We considered a P-value less than 0.05 as statistically sig-
nificant. All the statistical analyses were performed with
Quantitative reverse transcription polymerase chain SPSS 16.0 for Windows (SPSS, Inc.).
reaction
Compliance and ethics The author(s) declare that they have no conflict
Throat swabs and bronchoalveolar lavage fluid (BALF) were of interest.
collected from the respiratory tract of the patients at various
time points after hospitalization. Viral RNAs were extracted Acknowledgements The authors would like to thank a scientist who insists
from samples using the QIAamp RNA Viral Kit (Qiagen, on being anonymous. The authors would also like to thank Shunwang Li and
Heiden, Germany), and quantitative reverse transcription Xiaoyun Li who helped data analysis and making figures and tables. This
work was supported by the National Science and Technology Major Project
polymerase chain reaction (qRT-PCR) was performed using
(2017ZX10103011 and 2017ZX10204401), Chinese Academy of Medical
the primers and probes targeting the ORF1ab and N genes of Sciences Innovation Fund for Medical Sciences (2017-I2M-1-009), Shenz-
2019-nCoV as recommended by China CDC (http://ivdc. hen Science and Technology Research and Development Project
 Liu, Y., et al. Sci China Life Sci March (2020) Vol.63 No.3 373

(JCYJ20180504165549581 and JCYJ20170413141236903), China Post- S.M., Lau, E.H.Y., Wong, J.Y., et al. (2020). Early transmission
doctoral Science Foundation (2019T120147). dynamics in Wuhan, China, of novel coronavirus-infected pneumonia.
N Engl J Med, https://doi.org/10.1056/NEJMoa2001316.
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SUPPORTING INFORMATION
Figure S1 Computed tomographic (CT) scans of human cases with 2019-nCoV. CT scans of cases 1 and 3–12 taken at indicated date are
shown.

Figure S2 Assessment of the myocardial function in case 4. A and B, The ultrasonic cardiogram results. C, The left ventricular ejection
fraction (LVEF) and the left ventricular diameter (LV) at the indicated date.

Figure S3 The correlation between APACHE II scores and viral Ct value in 2019-nCoV-infected patients. The viral titers were detected
available in 10 patients with 2019-nCoV infection. APACHE II scores were detected from 12 2019-nCoV-infected patients. Spearman rank
correlation analysis (r) and P values are provided in the graph.

Table S1 The Ct values of different sample types from the same case determined by qRT-PCR

The supporting information is available online at http://life.scichina.com and https://link.springer.com. The supporting
materials are published as submitted, without typesetting or editing. The responsibility for scientific accuracy and content
remains entirely with the authors.