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Diaz Nelson1,2, Cusipaucar Gustavo1,2, Carcausto Eduardo1,2, Muñoz Sara1, Alarco Oliver1, Esquivel Robert1, Alave Jorge2,3
1. Internal Medicine Unit. Clínica Good Hope. Lima Peru.
2. School of Medicine. Universidad Peruana Union. Lima, Peru.
3. Infectious Diseases Unit. Clinica Good Hope. Lima, Peru.

Date of presentation: 26 March 2020
clinical case:
A 64-year-old male with past medical hystory of arterial hypertension and obesity who presenting 10 days of cough with expectoration, and five days before admission he presented fever, odynophagia and mild dyspnea. He was admmitted to respiratory symptomatic ward at Clinica Good Hope because of increased dyspnea.

At admission, the physical examination revealed fever (38.5°C), respiratory rate of 22 per minute, erythematous oropharynx, no pulmonary crackles. The laboratory results showed leukopenia(2700 cell/μL), lymphopenia (820 cell/ μL), C reactive protein 1.9 mg/dL, lactate dehydrogenase 518 U/L (normal value, 135 – 225 U/L), ferritin 1593 ng/mL, procalcitonin 0.12 ng/mL. Gasometry showed mild hypoxemia (PO2, 80.6 mmHg), mild hypocapnia (PCO2, 37.9 mmHg), oxygen saturation (SpO2) in 96% at fraction of oxygen (FiO2) of 28%. The chest X-ray showed peripheral interstitial infiltrates on lung bases (fig 1) and thorax CT scan revealed mild multifocal peripheral subpleural ground glass in both lung fields with consolidation (fig 2). The multiple RT-PCR (CLART PneumoVir test) from sputum for non SARS CoV-2 viral microorganism was negative. The Peruvian National Health Institute reported SARS CoV-2 RT-PCR from nasopharynx sample was positive. Patient started ceftriaxone 2 gr QD plus azithromycin 500 mg QD.

During follow-up, patient continued with fever and pulmonary crackels appeared. Gasometry revealed severe hipoxemia (PO2 64 mmHg, SpO2 in 93% at FiO2 of 21%), with lymphocytes of 1220 cell/μL, increased C reactive protein (12 mg/dL), increased lactate dehydrogenase (543 U/L), increased ferritin (3195 ng/dl), procalcitonin of 0.171 ng/mL. The chest X-ray monitoring showed increased interstitial infiltrate, and electrocardiography did not reveal significant alteration. The patient started optional treatment with hydroxychloroquine 400 mg BID on first day and 200 mg BID for next four days, plus azithromycin 250 mg QD.

On 3th day after the start hydroxychloroquine, patient persisted with fever and dyspnea, and electrocardiography showed prolonged corrected QT segment. Therefore hydroxychloroquine and azithromycin were stopped and methylprednisolone 0.5 mg/kg BID was started and planned for three days. On 3th day after steroids, patient experienced improvement of fever and dyspnea, and physical examination revealed decreased of pulmonary crackels. Laboratory results showed leukocytes 6880 with lymphocytes 2060 cel/μL, C reactive protein 1,045 mg/dL, lactate dehydrogenase 504 U/L, improvement of hipoxemia (PO2 77 mmHg, SpO2 in 96%, at FiO2 21%). On 6 days after steroids, patient was discharged with favorable clinical evolution.

Learned lesson:
The close monitoring of a patient with risk factors for severe COVID-19 allowed early and successful intervention using steroids. After discharge, the patient's clinical evolution was favorable.