Question normal

Zohaib Khan, Sukhdev Singh, Jahinover Mazo M.D., Abhiram Nagaraj M.D., Peter Mena M.D.

Department of Radiology
Richmond University Medical Center

A man in his 60’s with a known history of HTN, HLD and recent CVA (5 weeks ago) presented to the ED with c/o dry cough, SOB , fatigue and relapsing remitting subjective fevers of 2 weeks duration. Patient endorsed associated right sided pleuritic chest pain 5/10 intensity that worsened with inspiration. He also reported body aches, weakness, poor appetite and loose non-bloody diarrhea (x4/day) over the past 2 weeks. He denied any chills and vomiting or abdominal pain. He was seen by PCP 1 week prior for similar symptoms and CXR at the time was negative. He denied contact with any persons with similar symptoms or recent travel.

Physical Examination:
His initial vitals were: BP 100/75, HR 70, RR 16, T 98.1, So2 98% RA. Shortly after arriving in ED, the patient spiked a fever of 102.5F (rectal) which resolved with Acetaminophen. Chest and abdominal exam was benign.

Initial leukocyte count was 6.4k. Blood cultures and RT-PCR for Influenza A, Influenza B and RSV all returned negative. Nasopharyngeal swab returned back positive on hospital day 2 for COVID-19/SARS-CoV-2. EKG demonstrated normal sinus rhythm at 78 bpm, normal intervals, no acute ST-T changes. CXR showed RLL haziness suspicious for pneumonia and CT chest w/o contrast: Bilateral patchy ground glass opacities mainly lower lung fields and the periphery of the lung fields with no mediastinal adenopathy or pleural effusion.

In the ED patient was administered 1L 0.9% NS bolus, IV Ceftriaxone 1gm and PO doxycycline 100mg PO. Patient was admitted for management of CAP and placed on airborne/ contact isolation. Following positive COVID-19 result on Day 2, the patient was continued on Ceftriaxone 1g Q24h IV, Doxycycline 100mg Q12h and patient was started on Plaquenil (Hydroxychloroquine) 400mg Q12 for 24 hours then 200mg Q12 for additional 4 days.
On hospital Day 3, Patient developed SOB and desaturated to 72% on RA. He was started on 4L NC saturating at 95%. A Single dose of Solumedrol 60mg IVP was administered and ventolin MDI was given. Patient had subsequent resolution of symptoms.

Lesson Learned:
This case demonstrates that In addition to pulmonary symptoms, COVID 19 patients may present with a history of fluctuating fevers and GI symptoms. Vitals and Labs may be within normal limits. Imaging findings are nonspecific however; they may demonstrate ground glass opacities on chest CT and bilateral lower lung patchy opacities on CXR, suggestive of atypical/viral pneumonia. High clinical suspicion of COVID-19 cases should be isolated for contact precautions.