Question normal

Yale-Waterbury Internal Medicine
Waterbury Hospital, CT

Authors: Rohit Singh MD; Kristin Torre MD; Danise Schiliro MD

Date of presentation: 03/20/2020

We report a case of a 77-year-old woman who presented to the emergency department with complaints of dry cough, lethargy, and shortness of breath which started 2-3 days prior to her arrival. Her past medical history is significant for type 2 diabetes mellitus, hypertension, multinodular goiter status post thyroidectomy 3 years ago, and a provoked pulmonary embolism 2 years ago on rivaroxaban. She stated that she was in her usual state of health prior to the onset of symptoms. She lives with her husband and attends church regularly. She denied recent travel or any known sick contacts. She denied fever, loss of smell, chills, vomiting, diarrhea, or abdominal pain.

Examination:
Initial vitals showed: Temp 98.6F, HR 120s, BP 153/100, RR 20/min, oxygen saturation of 95% on room air. Physical exam showed: A comfortable appearing woman in no acute respiratory distress, intermittently coughing throughout the interview. Pulmonary exam was unremarkable (no wheezes, crackles), and the rest of the physical exam was benign.

Labs/Imaging:
Blood work showed a mild leukocytosis (13.7K) with a lymphocyte count of 1.1, elevated creatinine 1.8 (baseline around 0.7), and creatinine kinase of 1000 (3 days after admission). LFTs were normal. Influenza PCR was negative. Chest X-ray on admission was normal but the repeat chest X-ray on day 2 of admission showed possible bilateral infiltrates. EKG demonstrated sinus tachycardia, normal intervals with no acute ST-T wave changes. A nasopharyngeal swab was positive for SARS-CoV-2 on a real-time reverse transcription polymerase chain reaction (RT-PCR) assay 2 days after admission. Blood cultures drawn came back negative.

Treatment/Outcome:
Initially, the patient was afebrile, but subsequently developed a fever (Tmax of 103.2F). She defervesced by hospital day 5. She otherwise remained hemodynamically stable. Her acute kidney injury on admission resolved with intravenous fluids. She was treated with azithromycin and ceftriaxone due to concern of superimposed bacterial infection (pneumonia). Her oxygen saturation level started to drop on day 5, and she was started on oxygen supplementation (2L) via nasal cannula. Initiation of hydroxychloroquine was deferred given that she was improving clinically. During the course of hospitalization, her symptoms continued to improve (discharged on day 10 and feeling better).

Lessons Learned:
Available data on Covid-19 suggests that patients can develop hypoxia and respiratory distress 5-7 days after symptom onset, which is what happened with our patient. We have to be mindful that even if our Covid-19 patients remain stable during the initial course of their disease, respiratory distress can occur around 1 week after the onset of symptoms.
Isolation precautions also limit patient and doctor interactions which can lead to increased patient anxiety. Given our patient was hemodynamically stable, and thanks to technology, we were able to communicate with her multiple times per day via Facetime/Skype video conferencing.