Question normal

Oscar Perez, Talha Saleem, Asif Hitawala and Hussain Karimi

Case Presentation:
We present a case of a male in his late 40’s with significant PMH of DM II and HLD controlled with oral therapy who presented to emergency department in mid-march following a recent travel to Spain and Italy with complains of Fever up to 102 F at home, productive cough with yellow sputum, myalgia, frontal headache and watery diarrhea for two days. During that encounter, he had negative rapid PCR for Flu/RSV. CXR imaging showed ill-defined nodular shadows bilaterally and bibasilar subsegmental atelectasis. Given his recent travel history, he was screened for COVID-19. He was hemodynamically stable with no evidence of hypoxic respiratory failure or respiratory distress. He was discharged home from ED and advised to quarantine himself in his house and contact healthcare providers if the symptoms worsen in the following hours.
The next day, COVID 19 PCR test came back positive.
48 hours later he developed worsening SOB and rusty colored phlegm. He contacted his PCP who recommended evaluation in the emergency room immediately.

Physical exam:
Pertinent for tachypnea, tachycardia, use of accessory muscles and B/L coarse crepitation. O2 sat 88-92% on 6 liters. BP WNL.

Pertinent laboratory values:
Labs revealed lymphocytopenia. Initial ABG paO2 / FIO2 ratio 139 mmHg with normal PH and CO2.
Respiratory culture, blood cultures, MRSA PCR were negative. LDH mildly elevated and CRP up to 33.1 mg/dL.

Pertinent imaging:
Repeat CXR revealed ill-defined nodular shadows in both lungs with superimposed patchy groundglass densities (image attached) which have developed since the prior study.

CT scan was not performed due to XR findings and positive PCR test.

Treatment and outcomes:
In the ED, patient was given IV steroids, broad spectrum antibiotics & admitted to ICU for close monitoring.
Patient continued to have worsening respiratory failure therefore it was decided to electively intubate him and initiate lung protective ventilation strategy. Later on, he required vasopressor support, paO2 / FIO2 ratio dropped down to 85 mmHg, therefore PEEP was increased to 20 cmH2O.
After 72 hours of treatment chest X-ray has demonstrated minimal signs of improvement with significant change in his oxygenation: paO2 / FIO2 ratio up to 240 mmHg. PEEP requirement decreased to 12 cmH2O. Pressors have been weaned off.
He is currently in mechanical ventilation and managed for ARDS, he is receiving hydroxychloroquine and lopinovir-ritonavir. Remdesivir was not started due to concern of hypotension.

Lesson learned:
Patients with mild symptoms and positive test for SARS-CoV-2 virus can deteriorate rapidly. Every patient with positive results, should be followed closely as outpatient and advised to come back to the ED if symptoms persist or worsen.
Our patient was managed aggressively, and early elective intubation with lung protective ventilation should be considered in patients with worsening respiratory failure.