Severe COVID 19 Case with Atypical Presentation
Henry Ford Health System
Introduction: COVID-19 was brought to the attention of the WHO on December 31st, 2019 and classified a global pandemic on March 11th. As of March 26th, there were 2,856 cases and 60 deaths in Michigan..more »
Introduction: COVID-19 was brought to the attention of the WHO on December 31st, 2019 and classified a global pandemic on March 11th. As of March 26th, there were 2,856 cases and 60 deaths in Michigan, with 851 cases and 15 deaths in Detroit. Efforts to characterize risk factors for severe disease may improve clinical outcomes and inform resource allocation. Better understanding of the epidemiological and clinical characteristics of COVID-19 are essential to slowing transmission and treating patients. Below we detail the clinical features of a COVID-19 positive patient seen in early March, 2020.
Case Report: An 80-year-old female presented to the ED with fevers. She endorsed worsening fevers, watery diarrhea, abdominal pain, and myalgias of one week. She was lethargic and presyncopal for one day prior to presentation. She endorsed contact with sick members at home and denied travel history. Her past medical history was significant for resected colon cancer, T2DM, COPD, HTN, and CAD. She was a former smoker. On exam she was febrile and had lower abdominal tenderness. Her labs showed lymphopenia, thrombocytopenia, and mild hyponatremia. Influenza swab, viral panel, and legionella urine antigen were negative, prompting COVID-19 testing. Chest x-ray showed diffuse reticular opacities. Antibiotics were started and she was admitted on hospital day 2. She developed dyspnea, rales, and increasing oxygen demand through her hospitalization. COVID-19 testing resulted positive by day 4. Infectious disease recommended ribavirin and lopinavir-ritonavir. Her son was informed, and all contacts were advised to isolate for two weeks. On days 5 and 6 she improved clinically, though was not discharged due to concern she would not abide by self-isolation recommendations. Overnight, she had increasing oxygen demand and repeat chest x-ray revealed worsening infiltrates. She was intubated and transferred to the MICU on day 7. Inflammatory markers including LDH, CRP, procalcitonin, lactate, anion gap, aPTT, INR, and D-dimer were elevated. ABG revealed low PaO2 and low pH. Her IL-6 and fibrinogen levels were normal. She continued to decompensate with concern for septic shock, and had worsening bradycardia and hypotension, unresponsive to three vasopressors. On day 7, she expired.
Discussion: Our report of a COVID-19 patient that ended in their mortality provides important lessons for providers. The transmission mode was local spread, reflecting high transmissibility among family groups. Fevers are reliably present over the illness course, though seen in under half on presentation. Fatigue is common and was observed in our patient. Cough is common, though was absent here. Diarrhea is an uncommon presenting symptom, reducing initial clinical suspicion and potentially delaying diagnosis. Other characteristics seen in our patient reflect a growing body of evidence supporting high rate of morbidity and mortality in patients with COVID-19. Such populations, including critically ill elderly population, require ICU level care, with marked lymphopenia on admission labs, and elevated inflammatory markers across their hospitalization. Also, investigative treatments including Lopinavir-ritonavir, ribavirin, hydroxychloroquine, and azithromycin have yet to demonstrate clinical efficacy in large randomized controlled trials.
Wayne State University
Wayne State University Medical School
Henry Ford Health System