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Sarah Bliss, M.D., Kevin Seitz, M.D., Robin Stiller, M.D.
University of Washington Department of Medicine, Harborview Medical Center

Case presentation:
A woman in her 6th decade of life with a history of rheumatoid arthritis, not currently on medications, presented with encephalopathy, profound hypoxemia and shock.

History gathered from the patient’s family revealed she had been experiencing upper respiratory and flu-like symptoms including dry cough, postnasal drainage, sore throat, chills, headache and fatigue for two weeks. Four days prior to presentation, she was evaluated by her primary care physician and had unremarkable vital signs and exam. Two days later, however, she called back and reported worsening symptoms; she was started on azithromycin. She had had one sick-contact in the community who similarly reported flu-like symptoms for approximately two weeks.

On day of admission, the patient collapsed at home and was found nonresponsive and only to be moving her right upper extremity. First responders intubated her in the field with rocuronium and midazolam.

Physical exam:
On arrival to the emergency department, she was hypotensive to 80/50 mmHg, tachycardic to the 110s and experienced a desaturation event to 60%. With administration of high flow nasal oxygen, she had slow recovery to saturations in the low 90s. She demonstrated no spontaneous movements. Her pupils were equal and reactive bilaterally. She was tachycardic and in a regular rhythm. No focal lung sounds were appreciated on exam. She otherwise had a benign abdomen and mild lower extremity pitting edema.

Pertinent laboratory values:
Initial diagnostics obtained in parallel were notable for leukocytosis to 13K/μL with neutrophilic predominance of 81% and lymphopenia to 0.7K/μL on differential, anion gap of 15 with normal electrolytes, and lactate of 11mmol/L. Her arterial blood gas showed hypercarbic and hypoxemic respiratory failure with pH 7.26, pCO2 of 58mmHg and pO2 of 96mmHg while respiring gas with an FiO2 of 1.0.

Pertinent imaging:
Chest computed tomography revealed multiple bilateral multifocal patchy consolidations with superimposed ground glass (image attached). Her CT head showed bilateral acute to subacute infarcts in multiple territories, concerning for embolic phenomena.

Treatment and outcomes:
Blood cultures were obtained and the patient was started on empiric antibiotics with vancomycin, cefepime and azithromycin. Respiratory viral panel yielded negative influenza and RSV however positive COVID-19. The patient was admitted to the medical intensive care unit on airborne precautions. She remained critically ill with severe acute respiratory distress syndrome and P:F ratio <100 mmHg. Lung protective ventilation was trialed but high oxygen needs persisted. She was treated for presumptive distributive shock and though adequate mean arterial pressures were maintained on maximum doses of two vasopressors, she had ongoing evidence of tissue hypoperfusion including precipitous renal failure. Given her profound respiratory failure and shock in the setting of concurrent multifocal cerebrovascular accidents, the decision was made to transition the patient to DNR and she experienced asystolic cardiac arrest approximately 12 hours after admission.

Lessons learned:
As rapid community spread increases prevalence of this disease, we must remain vigilant in considering COVID-19 on the differential or as a contributor to many presentations, importantly high acuity clinical scenarios.

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