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Mauricio Mora-Ramírez MD; Guadalupe D. Elguea-López MD; Paulina Melgoza-Hernández MD; Juan Manuel Mejía Aranguré MD, PhD.

Department of Internal Medicine; Hospital General de Zona 8 IMSS, Mexico City, Mexico.

Date of presentation: March 19, 2020

Case Presentation: A 33 years-old man with no relevant history. He was in contact with two confirmed patients with COVID-19 infection who had recently traveled to Spain and Japan, respectively. He presented symptoms such as headache, persistent fever, vomit, and diarrhea within the first 12 hours after contact in March 12, 2020. Said symptoms lasted for 5 days, and he was misdiagnosed with an infectious gastroenteritis at the emergency room during the first visit. He was sent to home isolation with antibiotic treatment and glucocorticoids for 4 days during which he did not present any clinical improvement.

Physical Exam: He was reevaluated in the emergency room on March 18th 2020, because he presented dyspnea, dry cough, tachypnea (30-35 bpm), and oxygen saturation between 70%-75% at ambient air, with body temperature of 38.5°C.

Laboratory Findings: The initial biochemical tests showed a moderate leukocytosis with 15,000 cell/mm3, neutrophilia with 14,000 cell/mm3, and lymphopenia with 900 cell/mm3. Hemoglobin: 15.5 gr/dl, platelet count: 247,000 per πl, Reactive C-protein: 7.16 mg/dl, LDH: 623 U/ml. The rest of the parameters were unremarkable. We performed a PCR-RT test that yielded a positive result after 4 days; therefore, the COVID-19 infection diagnosis was confirmed.

Pertinent imaging: The initial X-ray showed peripheral infiltrates and right basal consolidation pattern (Figure 1).

Treatment: He was admitted into the Internal Medicine Department in March 19th 2020 and was isolated in a room on march 23rd 2020, because he developed severe pneumonia (FINE>3 pts) during the last 7 days. Initially, he received levofloxacin 750 mg/day and chloroquine 500 mg BID, as well as, lopinavir- ritonavir 200/50 mg BID along with supportive care and oxygen therapy. We decided to remove lopinavir/ritonavir after 5 days, due to gastrointestinal adverse effects, such as, nausea and abdominal discomfort; nevertheless, he presented clinical improvement in respiratory symptoms and did not present fever. In March 25th, his vitals remained stable; he remained 72 hours without fever and an oxygen saturation greater than 94% without oxygen therapy. After seven days with medical therapy and support, we decided the hospital discharge.

Lesson learned: This report highlights the unusual clinical presentation of a patient with COVID-19. In a country with limited health sources, this case could be elucidative. First, keep in mind that the initial symptoms can be developed in the first twelve hours and that they can be unusual signs, such as, diarrhea and abdominal pain, reported in less than 3% of all confirmed cases; also, remember we should keep clinical suspicion in patients with recent travels or contact with people who have traveled recently and present clinical manifestations. Second, triple therapy for severe cases could be an option if you don’t have other drugs such as hydroxychloroquine or azithromycin, while monitoring the adverse effects, such as, arrhythmias and abdominal discomfort.