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Introduction:
Pandemics are major concern for health authorities today. For centuries, pandemics—predominantly influenza—have devastated humanity by overwhelming health care systems and disrupting the economies of nations.(1) The most recent pandemic of the novel coronavirus--SARS-CoV-2-- has progressed rapidly, and will not only result in significant mortality, but it will also change the world as we know it.(2) In this article we present the first known community-acquired case of COVID-19 in Pakistan received at Aga Khan University Hospital in Karachi.
Case:
A 77-year-old male with a history of hypertension, diabetes, and squamous cell carcinoma (SCC) of the larynx presented to the Emergency Department (ED) with the complaints of difficulty in breathing for few hours. He also noted a mild sore throat and subjective fever with a productive cough for the past two days. Neither he nor anyone in his family had traveled recently. A past surgical history revealed laryngectomy, total neck dissection, partial thyroidectomy and tracheostomy formation for SCC of the larynx performed seven years ago. Chemotherapy was recommended, but he did not begin treatment due to financial constraints. On the day of admission in ED, his initial vital signs were a blood pressure of 148/86 mmHg, heart rate of 98 beats/min, oxygen saturation of 97% on room air, respiratory rate of 28 breaths/min and temperature 36.8 Celsius. On lung auscultation, crepitations were identified in the mid and lower zones on the left side. He was also noted to have thick yellowish secretions from stoma site. Relevant laboratory investigations included a hemoglobin 14.4 g/dl, hematocrit 42.5%, white cell count of 9.8x109/L (neutrophils 83.1%, lymphocytes 8.6%), platelets 266x109/L, C-reactive protein 27.43 mg/L, and serum creatinine 1.5 mg/L. The remainder of his electrolytes were within the normal ranges. D-Dimer 0.4 mg/L FEU, Serum Ferritin 56.4 ng/ml, Procalcitonin 0.122 ng/mL Chest radiography showed evidence of peri-hilar vascular congestion (Figure 1). A 12-lead electrocardiogram showed a normal sinus rhythm. Due to a high suspicion for COVID-19, to the patient was then placed in an isolation room, and a nasopharyngeal swab SARS-CoV-2 and H1N1 influenza was sent. A bedside point-of-care ultrasound was performed which showed B-lines, pleural thickening, and consolidation of the left lung parenchyma (Figure 2). There was no left ventricular dysfunction or pericardial effusion. Due to excess stomal secretions, the patient was nebulized with 3% hypertonic saline and gentle suctioning was performed with personal protective equipment (PPE),including double gloves, gowns, N-95 respirator mask and eye shield. IV hydration with normal saline 0.9% was infused at 75ml/hour during hospital stay. He developed a fever to 101.0°F and was given intravenous (IV) paracetamol. Given the recent introduction of an expedited hospital admission policy for patients with suspected COVID-19, the patient was transferred urgently to a High Dependency Unit with negative pressure isolation availability. Otolaryngology consultation occurred for management of the stoma, which was found to be stenosed. The patient was maintained on IV ceftriaxone (2000 mg) and azithromycin (500mg) orally as well as regular stoma care with nebulized 3% hypertonic saline and suctioning Oseltamivir (150mg stat) was also started prophylactically for suspected H1N1. Approximately 10 hours into his admission, the patient decompensated and was in PEA arrest. Resuscitative efforts were started and continued for 40 minutes. Due to no return of spontaneous circulation, death was declared to the family.
On the ensuing day, the qualitative polymerase chain reaction (PCR) test for SARS-CoV-2 was reported as positive and H1N1 influenza test as negative. CORONA PCR test was performed by serum RNA extracted from the specimen and amplified by a reverse-transcriptase method. Targeted polymerase chain reaction (PCR) amplification was performed using specific primers and probes to the E gene of the 2019 novel Coronavirus (SARS-CoV-2). Target was detected using a real-time PCR based assay. Internal control targets for assay validation was based on the human RNA P gene. This assay uses the European Virus Archive control reagents.(3)
All healthcare workers involved in direct care of the patient were immediately informed to report for testing, N-95 fit test was failed in majority of health care workers as a consequence immediately 4 doctors and 5 staff were sent for covid testing and home isolation. The issues identified in the management are summarized in Table I.

Discussion:
A detailed history, including contact tracing, is essential information not only for an individual patient, but is vital to control and containment at the population level during a pandemic. A more thorough discussion with this patient’s family revealed that he had attended religious proceeding in a community hall three days earlier. This is the first reported case of community transmission of SARS-CoV-2 in Pakistan. This was an alarming point as “Patient 31” in south Korea was a 61-year-old woman attended Church she and 37 other members of the church were tested positive for the novel coronavirus, and 52 additional churchgoers have shown symptoms of infection.(4) Ideally, strict social distancing would already be in practice to prevent community transmission(5), however this is often very difficult to achieve, particularly early on a pandemic, due to complex issues--from social, cultural, religious, and economic considerations to communication and messaging approaches from authorities and public health officials.(6) Once a patient does present, however, prompt suspicion and timely isolation of patient is key due to the risk for transmission, not only to health care personnel, but other patients as well. Unfortunately, this patient’s confounding comorbidities, among other factors, resulted delayed isolation and use of PPE, and, consequently, four doctors and five nursing staff who came in direct contact with the patient during the patient’s ED course were self-isolated. Additionally, this patient received nebulizer treatments, which was a potential hazard to others throughout the ED.(7) In a low middle income county LMIC, healthcare system is already limited and healthcare professionals are already scarce. In case of self-isolation of many Emergency Physicians and healthcare staff, the delivery of care is at stake of being jeopardized.
In conclusion, clinical and laboratory workup of SARS-CoV-2 infection can be masked by underlying comorbid conditions especially patients who are immune-compromised.(8) Furthermore, infections in these patients can rapidly progress, so critical care resources should be readily available and clear protocols should be in place to manage sudden deterioration in clinical status.(9) Early suspicion with robust screening processes, awareness of asymptomatic transm