Discussion
We illustrate three cases of atypical COVID-19. All patients were admitted into single room facilities, where they were screened positive. These patients could otherwise have been admitted to cohort cubicles where the propensity for secondary spread, would have been higher.
The 2003 SARS-CoV-1 outbreak in Singapore saw sequential spread involving three major acute care hospitals, the first arising following the hospitalization of a returning traveller with atypical pneumonia. Nosocomial transmission of SARS-CoV-1 resulted, taking a total of three weeks to control in the first hospital cluster. [2] The index patient central to another cluster of 60 patients at a second hospital in March 2003, had presented with atypical features, masked by E. coli bacteremia. [2-3] Our small case series illustrate the vulnerability of our inpatient cohort where atypical COVID-19 presentation can potentially result in secondary nosocomial transmission.
Contrary to the earlier SARS-CoV-1 outbreak, Singapore’s first local case of SARS-CoV-2 was diagnosed promptly on January 23, 2020 in a traveller from Wuhan, China. He presented with typical febrile respiratory symptoms, and was diagnosed with pneumonia upon hospitalization. [4] Asymptomatic transmission of SARS-CoV-2 adds to the challenge of SARS-CoV-2 diagnosis and containment. Asymptomatic ratio of COVID-19 has been estimated to be as high as 30.8% amongst Japanese nationals evacuated from Wuhan, China. [5] This is well-illustrated by our Case 3, where an ongoing outbreak in that setting, raises the pre-test probability of infection and underscores the immense challenge at curtailing transmission.
A high index of suspicion, strict infection control and prompt isolation measures are crucial in protecting our healthcare system from nosocomial SARS-CoV-2 outbreaks.