Question normal

Courtney Enix, M.D., Kevin Seitz, M.D., David Roach, M.D., Robin Stiller, M.D.
University of Washington Department of Medicine, Harborview Medical Center

Case presentation:
A man in his 6th decade of life with no significant past medical history presented with acute onset fever and difficulty breathing.

The patient had been in his usual state of good health until late 2019, when he experienced a polytraumatic injury, requiring prolonged hospitalization and ultimate discharge to a skilled nursing facility (SNF) for ongoing rehabilitation. He had been residing at the SNF since, and in the week leading up to admission started to develop cough productive of sputum. On day of admission, he developed fevers and tachypnea and was brought in for evaluation.

Physical exam:
On arrival, he was found to be febrile to 40.7°, tachycardic to the 140s, and tachypneic to the low 40s requiring 15L by nonrebreather to maintain an SpO2 greater than 90%. The patient was in distress and unable to speak in full sentences. He was using his accessory ventilatory muscles; breath sounds were coarse bilaterally. His cardiac rhythm was regular and he was warm and well perfused.

Pertinent laboratory values:
A venous blood gas revealed a pH of 7.46 and pCO2 of 45 mmHg. Lab work was remarkable for hypernatremia to 151 mEq/L, hypokalemia to 3.1 mEq/L, creatinine of 1 mg/dL (baseline 0.5mg/dL) and BUN of 39mg/dL. He had a leukocytosis to 16K/μL with neutrophilic predominance to 82% and mild leukopenia 0.9K/μL. His liver function tests and lactate were normal. Influenza and RSV were negative.

Pertinent imaging:
Chest radiograph demonstrated bilateral patchy opacities but notably improved from prior films in our system from months before this admission. A CT Pulmonary Embolism Protocol was obtained, as well, and showed bronchial wall thickening, nodular consolidations and centrilobular nodules favored to represent endobronchial spread of infection (image attached).

Treatment and Outcomes
Blood and urine cultures were obtained and the patient was started on empiric antibiotics with cefepime, linezolid (due to vancomycin allergy) and azithromycin. He was admitted to the medical intensive care unit (MICU) for ongoing management of his respiratory failure. While in the MICU, the patient continued to have hypoxemia and tachypnea despite oxygen delivery by high flow nasal cannula. A conversation was held with the patient’s wife and durable power of attorney, who felt that further invasive interventions would not be in line with the patient’s goals of care and he was transitioned to comfort based measures. He was transferred to the acute care medicine service and died two days later. Post-mortem COVID-19 testing was performed and later confirmed to be positive.

Lessons learned:
This case highlights the increased risk to individuals who reside in communal settings, particularly those with other medical comorbidities. Vulnerable populations deserve close consideration of COVID-19 testing.

*This case has been reviewed by a NEJM editor.*