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Aquino Williams MD, Lance Alquran MD, Ummi Khan MD, Roveena Goveas MD.

Dept. of Internal Medicine
Hackensack Meridian Health -Mountainside Medical Center.

Case Presentation:
Male, in the 6th decade of life, PMHx of NIDT2DM, COPD w/o home O2, HTN and hypothyroidism who was initially brought to the hospital by EMS after being found unresponsive at home by neighbors. Prior to the collapse, the patient reports having symptoms of dizziness X1 day, cough, fatigue and unable to keep his balance. However, he did not have any of the typical suspicious symptoms, which correlated to COVID-19. He denied dyspnea, myalgia, GI symptoms, travel history, sick contacts, headaches, visual changes, Loss of consciousness, palpations or chest pain.

Physical Exam:
Upon admission patient was AAOx3. Vitals were a temp of 101, BP 137/82, HR 72, RR 18, SPO2 of 99% on 6L NC. Dry, Pale skin, rales in present b/l LL.

Pertinent laboratory Findings:
CK >5,000, mild elevation in AST & ALT with normal lactic acid, leukocyte count, no bands, negative rapid flu.

Pertinent Imaging:
Admission CXR unremarkable.

Treatment and Outcomes:

Patient was admitted to medical floor and was started on ceftriaxone and azithromycin for presumed pneumonia vs bronchitis leading to his COPD exacerbation. Patient had a one time read of fever on admission; vitals and labs were relatively stable during the first 48hrs. On day 2 of admission, patient remained stable, asymptomatic with benign physical exam however, things rapidly changed in the afternoon after 52 hours into admission, He became febrile with a T 101.7, and his oxygen saturation declined to 88% on RA and 92% on 6L NC. Notably he was found to be diaphoretic but able to talk in full sentences. Physical exam was significant for new wheezing in bilateral lung bases. Given his deteriorating condition, it was decided to test patient for COVID-19 given the rapid spread of virus nationwide. Prior to this point the patient did not have any of the typical criteria that were identified in current papers or guidelines from the CDC, besides low-grade fever. We initiated airborne precautions and obtain necessary samples (respiratory viral panel, COVID-19, rapid strep, throat culture) using PPE. An ABG while on room air which showed 45% PaO2 and 84% saturation.

CTA showed: Negative for pulmonary embolus however was notable for Subpleural and peripheral interstitial infiltrate sign suggestive of COVID-19 vs other viral infections. Whereas prior CXR on admission was benign.
Due to increased risk of aerosolization while on BiPAP, patient was placed on 50% high flow nasal canal (HFNC) which improved his saturations to 98% and PaO2 to 102, however we maintain a low threshold for possible intubation. He maintained a stable respiratory status for several days, including ambulation without becoming symptomatic/desaturating.
Respiratory status was stable for ~ 4days while patient was on (HFNC), with saturation maintaining above 92%, without signs of acute distress. However patient continued to spike fevers intermediately. We were able to decrease Oxygen requirements on HFNC from 50% to 35%, where he was able to maintain his SaO2 above 94%. Unfortunately after 3 days of HFNC, only the COVID-19 test returned positive, his saturations worsened leading to intubation and transfer to the ICU. He was found to have ARDS secondary to COVID-19, ventilation setting were adjusted for the management of ARDS, improving oxygenation however PCO2 became elevated. Noticeably patient BP declined and requiring placement of a central line. During the interim 3 days after confirmation of COVID-19, Plaquenil and Kaltera were initiated.

Unfortunately, after ~ 4days his ICU stay and on ventilator (AD#10) patient went to into cardiac arrest and were unable to achieve ROSC.

Lessons Learned:

Upon reflection it was notable that our patient’s ABG and CT scan were similar to another patient. Both showed hypoxemia, suggestion of A-a gradient and had similar CT findings.
This case illustrates that our patient had no red flags or high-risk factors for COVID and thus was not tested on admission due to his stable respiratory condition. However, his condition deteriorated leading to COVID- 19 testing which was positive. We need to remain vigilant in considering this novel virus in patients’ with other comorbid conditions especially underlying lung disease, regardless of the travel history. Especially with the likelihood of asymptomatic carriers. We need to have low threshold for testing COVID-19 in certain populations with underlying comorbidities.