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Department of Radiology
Richmond University Medical Center

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

Presentation

A female in her 40’s with no known medical history presented to the ED for 1 week history of fever. She was diagnosed with a UTI one week prior and completed a one week course of Ciprofloxacin. She continued to be febrile with a Temp of 101.2 at home which prompted her to come to the ED. Patient was afebrile on presentation. She also endorsed a headache and chest tightness with no modifying factors. She denied dyspnea, cough, chills, sore throat, rash, earache, n/v/d or urinary symptoms. She denied recent travel or contact with any persons with similar symptoms.

Physical Exam:

Patient was tachycardia on presentation with a HR of 106, her other vitals were wnl: BP 128/72, T 98.6, R20. Physical exam was otherwise unremarkable.

Labs/Imaging:

CBC revealed leukopenia with WBC count 2.3k with low neutrophils and lymphocytes. RT-PCR for Influenza A, Influenza B and RSV all returned negative. A Nasopharyngeal swab was obtained which returned positive for COVID-19 on day 2 of admission.

CXR showed no infiltrates or vascular congestion, and was read as negative. CT Chest was performed to rule out pulmonary embolism. CT showed a large region of ground glass opacification with some areas showing a characteristic “Crazy-Paving” pattern in the posterior left lower lobe, peripheral left lower lobe and peripheral right middle lobe concerning for atypical/viral pneumonia.

Treatment/Outcomes

In the ED patient was administered Azithromycin 500 mg IV, Ceftriaxone 1 g IV. Patient was admitted for management of CAP and placed on airborne/ contact isolation pending COVID-19 results. On Day 2 of admission COVID-19 pneumonia was confirmed. Patient was continued on Azithromycin 500 mg IV, Ceftriaxone 1 g IV. Patient remained stable on room air and no additional therapy was recommended unless patients status worsened.

Lesson Learned

This case demonstrates that healthy relatively young patients are susceptible to COVID-19 pulmonary involvement. Early signs of pulmonary involvement may be difficult to spot on CXR. High clinical suspicion of COVID-19 should warrant early isolation precautions. Looking back at the chest x-ray there were visible subtle markings on the chest xray of an atypical pneumonia, such as a left lower lobe hazy appearance which CT showed it to be a ground glass appearance and crazy paving pattern.