Question normal

Case Presentation:
A 40-year-old man from Central America with limited English proficiency, history of uncontrolled diabetes, hypertension, and meniscal knee injury presented to clinic for routine follow up for diabetes. He participated in universal COVID-19 symptom screening at the front desk of his clinic, denied fever and cough, thus was not isolated or given a mask. The interview with his resident primary care provider centered on his poorly controlled diabetes. Toward the end of the encounter, he reported five days of night sweats with occasional subjective fevers. He denied any recent travel. His review of systems was remarkable for 10-pound weight loss in 3 weeks that he attributed to intentional dietary changes. He denied cough, congestion, or other systemic symptoms.

A chest x-ray was ordered to rule out possible reactivated tuberculosis.

Physical Exam:
The patient was hemodynamically stable: normotensive, afebrile, without signs of hypoxia. The patient exhibited no signs of respiratory distress, without tachypnea or abnormal cardiopulmonary findings. The oropharynx exam was normal, without cervical adenopathy or pharyngeal exudates. Lung exam was normal to auscultation. The rest of the exam was deferred.

Pertinent Imaging:
His chest x-ray was notable for right upper lobe opacity, possible right cavitary lesion, and left lower lobe reticular opacities. A chest CT was ordered the following day and notable for multiple bilateral ground glass opacities with peripheral distribution highly concerning for COVID-19 disease.

Pertinent Laboratory Values:
The patient exhibited no abnormal values in any of his blood lines. Respiratory syncytial virus and influenza testing were negative.

Treatment and outcomes:
Due to the patient’s chest CT findings, he was deemed high risk for COVID-19 and was tested by physicians, now using personal protective equipment. He was discharged from clinic with instructions to self-isolate at home. Thirty-six hours later testing for quantiferon was negative and for COVID-19 was positive. His resident primary care provider was asked to self-quarantine given her unprotected exposure.

Despite counseling from language concordant providers, the patient did not understand that he likely had a contagious disease, either tuberculosis or COVID19, and the need to self-quarantine. When medical staff called him to share his test results, he was not self-isolating. As is common in this area, the patient shared an apartment with unrelated adults. Fearing contagion, his apartment mates evicted him. He found temporary housing but due to progressive symptoms and impending homelessness presented to the Emergency Department three days later. He was admitted with tachycardia (120), fever (39.4 Celcius), and progressive cough. He was treated with one dose of ceftriaxone and azithromycin and initiated on hydroxychloroquine for treatment of COVID-19. His vital signs normalized, he never developed hypoxia, and blood cultures were negative within 24 hours. Due to his housing status, he remains in the hospital—stable—awaiting discharge to a secure location to complete his quarantine.

Lessons Learned:
1. COVID-19 can present with a highly abnormal chest x-ray yet minimal symptoms. During this epidemic, COVID-19 should be considered in the differential diagnosis of fever and weight loss along with tuberculosis, malignancy and other, more traditional illnesses.

2. Patients can experience COVID-19 complications due to both medical and social vulnerability. This patient’s social vulnerabilities included marginal housing, limited English proficiency, low health literacy, and poverty. His poor outcomes from COVID-19 including clinical deterioration requiring prolonged hospitalization were exaggerated by his unstable housing.

3. In the ambulatory setting, universal testing of asymptomatic, mildly symptomatic and frankly symptomatic patients is essential to containing COVID-19 spread. At the time of presentation, this patient’s healthcare system only had the capacity to test patients with high-risk travel or classic symptoms of fever and cough. Because the patient fit neither category, he exposed multiple healthcare providers and community members to COVID-19.

4. Public health and healthcare delivery systems must collaborate to actively address patients’ social vulnerability; together identifying creative solutions to mend health disparities.