Corresponding Author:
Dr. M Phani Krishna
3-1-39, Nagendra Nagar,
Nellore – 524002,
Andhra Pradesh,
India
Abstract: Coronaviruses are well known human pathogens known to
cause respiratory illness. In the first week of December 2019, a cluster
of cases diagnosed as “pneumonia of unknown aetiology”, were reported
in Wuhan, Hubei province in China. A novel coronavirus was isolated from
these patients and it was named as SARS-CoV-2 and disease as COVID-19.
On March 11th 2020, COVID-19 was declared as a
pandemic by W.H.O.
Most common clinical manifestations of COVID-19 are fever, dry cough,
dyspnea, fatigue, myalgia, sore throat, expectoration, hemoptysis,
nausea, diarrhoea, abdominal pain and headache. But pleuritic chest pain
as lone presenting symptom with COVID-19 is not reported till date. We
present a case of 62-year-old gentleman who presented with worsening
long standing pleuritic chest pain and was subsequently diagnosed to
have COVID-19.
Keywords: SARS-CoV-2, COVID-19, Pleuritic chest pain.
Key clinical message : Knowledge about rare and unusual
presentations of this newly emerging pandemic is very important for
clinicians as missing a case may result in further spread of infection.
This case highlights the importance of imaging in COVID-19
Background : Coronaviruses are well known human pathogens known
to cause respiratory illness. These are largely divided into 4 genera
namely α, β, γ, and δ. α coronaviruses like 229E, NL63, OC43 and HKU1
are known to cause seasonal mild respiratory illness where β –
Coronaviruses like (severe acute respiratory syndrome) SARS CoV-1 and
(middle east respiratory syndrome) MERS CoV were responsible for two
epidemic outbreaks in 2002-03 and 2012- 13 respectively. In the first
week of December 2019, a cluster of cases diagnosed as “pneumonia of
unknown aetiology”, were reported in Wuhan, Hubei province in China. On
January 7th 2020, a novel corona virus was isolated.
It was named as Severe acute respiratory syndrome corona virus 2
(SARS-CoV-2) and disease was named as corona virus disease-19 (COVID
-19) by World health organisation (WHO). On March 11, 2020, COVID-19 was
declared as pandemic by WHO. As on 20-05-2020 about 4 731 458 cases and
316, 169 deaths were reported affecting around 216 countries around the
globe (1).
SARS CoV-2 results in milder forms of disease in most of the cases but
it has high infectivity. Elderly and people with underlying
co-morbidities are at higher risk of critical illness. Most common
clinical manifestations of COVID-19 are fever, dry cough, dyspnea,
fatigue, myalgia, sore throat, expectoration, hemoptysis, nausea,
diarrhoea, abdominal pain and headache (2,3). But
pleuritic chest pain as the sole presentation is very rare with
COVID-19. We report a case of 62-year-old gentleman who presented with
worsening long standing pleuritic chest pain and he was subsequently
diagnosed to have COVID-19.
Case report :
A 62-year-old male has been presented to our emergency department with
the complaints of severe chest pain, more on left lateral side for 1
week which got worsened since 1 day. He had no history of fever, cough,
sore throat, shortness of breath. No history of sick contact or recent
travel. His medical history is significant for diabetes mellitus type 2,
systemic hypertension, old cerebrovascular accident and hypothyroidism.
He had sustained a road traffic accident in second week of March 2019
and he was managed conservatively elsewhere. In view of persistent chest
pain he was admitted in our hospital. On evaluation, electrocardiogram
(ECG), Chest X-RAY PA view and echocardiogram were found to be normal.
Computed tomography (CT) scan chest revealed fibrotic parenchymal
strands in left lower lobe, pleural tags with thickening in upper lobes;
soft tissue and bony thorax did not show any abnormality (Figure: 1) .
He was managed conservatively and was discharged. Again in the last week
of March, he presented to outpatient department with complaints of high
grade fever (Temperature – 103℉), cough and left side chest pain.
Repeat chest X-Ray was normal. He was managed with oral antibiotics and
recovered completely.
On admission he had pulse rate of 74/min, blood pressure 110/70 mm of
hg, and he was mildly hypoxic requiring 2 litres/min of oxygen via nasal
prongs. Systemic examination was unremarkable. A 12-lead ECG showed
normal sinus rhythm, no significant ST-T changes. Troponin I was within
normal limits. The patient’s full blood counts demonstrated normal
leucocyte count (8.6×109/L) with mild eosinophilia,
monocytosis ( Neutrophils-45%, lymphocytes- : 34%, eosinophils -9%,
monocytes -12%), haemoglobin of 113 gm/lit and platelets of
3.43×109/L . Baseline biochemical parameters were
within normal limits.
The patient underwent CT-scan chest on the same day and it revealed
patchy ground glass opacities predominantly peripheral in both lungs
involving all lobes with sub pleural reticulation in both lower lobe
(Figure: 2). Nasopharyngeal swab was sent for COVID-19 testing by RT-PCR
and it was reported equivocal. Given the current prevalence of COVID-19
and imaging highly suggestive of viral aetiology, we shifted the patient
to an isolation room and proceeded with repeat testing which turned out
to be positive. He was shifted to designated COVID-19 hospital (Part of
our network) and was continued on supportive care and empirical
antibiotics (Inj. Ceftriaxone 2gm IV OD and T. DOXY 100mg PO BD).
Inflammatory markers like ferritin, C - reactive protein, and lactate
dehydrogenase were all within normal limits and but D-Dimer levels were
mildly elevated (618 ng/ml). Vitamin D levels (20) were low and started
on supplements. Blood culture, sputum gram staining and cultures did not
show any significant growth. Sputum X-PERT MTB was negative. Antibiotics
were withheld and with appropriate measures his oxygen requirement came
down.
With signs of clinical improvement repeat testing done
5th day of illness was negative. But the test repeated
after 24 hours again turned out to be positive. Though patient was
clinically stable, as per local guidelines he needs to come out negative
in two tests 24 hours apart. Repeat testing done on
10th and 11th day of illness were
negative. He was discharged and was reviewed a week ago as outpatient,
his chest pain subsided and he is doing perfectly well.
Discussion :
SARS CoV-2 is an enveloped positive sense single stranded RNA virus. It
is spherical in shape with spikes projecting from the surface of its
envelope giving it a crown like appearance, hence the name coronavirus.
The structural proteins include Spike(S), envelope (E), transmembrane
(M), nucleocapsid (N). Spike protein is an important determinant of
virus entry into host cells and nucleocapsid plays an important role in
pathogenesis, replication and RNA packing (4).
Incubation period of COVID-19 ranges between 2-14 days with median of
5.2 days (5). Men are affected more and median age is
57years which is consistent with our patient (A gentleman above 60 years
of age). The risk for severe disease increases by 58% for every 10
years increase in age (2). Most of the clinical
features are non-specific and may not reliably establish the diagnosis
of COVID-19.
Classical presentation is fever, cough with dyspnea and bilateral chest
infiltrates. Fever was seen in 92% of patients, cough in 70-75%,
fatigue in 75%, and chest tightness in 49-62% of patients(2, 3). Other reported symptoms were anorexia,
myalgia, sputum production, rhinorrhea, and headache. Altered smell or
taste can be the first apparent manifestation in mild category of
patients and it was seen in around 64% of patients(6). Ocular manifestation like increased secretions
and conjunctival hyperemia were reported. SARS-CoV-2 viral RNA was
detected in tears (7). Gastrointestinal symptoms like
diarrhea can be the presenting manifestation in COVID-19.
Though viral pneumonias are associated with pleurisy, it has not been
reported till date in association with SARS-CoV-2. After extensive
review of literature we did not find a case of COVID-19 with pleuritic
chest pain alone as presenting manifestation. In fact it is CT-Scan
chest which helped us in arriving at a diagnosis, which explains the
importance of imaging in COVID-19. In a study done by Bai HX et al.,
radiologists in China and the United States were able to distinguish
COVID-19 from viral pneumonia on chest CT with high specificity but
moderate sensitivity(8). The peripheral lung
involvement on CT chest with the background of road traffic accident may
explain the worsening pleuritic chest pain in our patient.
Another interesting learning point was about RT-PCR interpretation. In
our case initial test was reported equivocal. But chest imaging being
highly suggestive of viral pneumonia, we repeated RT-PCR test next day
and it turned out to be positive. He improved well with supportive
measures and repeat testing done on 5th day was
negative. But surprisingly on 6th day it turned out to
be positive again. Respiratory isolation measures were continued along
with supportive measures and two consecutive tests done on
10th and 11th day were reported
negative. All the inflammatory markers like CRP, ferritin, and LDH were
within normal limits and D-dimer levels being not significantly elevated
would explain the milder form of disease and favorable outcome in our
case. He was reviewed as outpatient 2 weeks later and he was doing well.
Conclusion : Key steps to contain the spread of infection
include active case finding and isolation of positive cases, contact
tracing and quarantine, physical distancing of at least 6 feet at public
places and cough etiquette. Knowledge about rare and unusual
presentations of this newly emerging pandemic is very important for
clinicians as missing a case may result in further spread of infection.
This case highlights the importance of chest imaging findings in
diagnosis and importance of being vigilant about atypical presentations
of COVID-19.
Conflicts of interest : Nil
Funding : Nil
Author contribution : All authors contributed equally
References :
- Corona virus Disease 2019 (COVID-19) Situation Report – 120. World
Health Organization. Published May 19, 2020. Accessed May 20, 2020.
https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200519-covid-19-sitrep-120.pdf?sfvrsn=515cabfb_2
- Wang et al., (In Press) “Clinical Course and Outcomes of 344
Intensive Care Patients with COVID-19.
Am J Respir Crit
Care Med. 2020 Apr 8.
doi: 10.1164/rccm.202003-0736LE
- Chen Tao, Wu Di, Chen Huilong, Yan Weiming, Yang Danlei, Chen Guang et
al. “Clinical characteristics of 113 deceased patients with
coronavirus disease 2019: retrospective study” BMJ 2020; 368
:m109
- X. Li et al., “Molecular immune pathogenesis and diagnosis of
COVID-19” Journal of Pharmaceutical Analysis 10 (2020) 102-108.
- Lauer SA, Grantz KH, Bi Q, et al. The Incubation Period of Coronavirus
Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases:
Estimation and Application [published online ahead of print, 2020
Mar 10]. Ann Intern Med . 2020; M20-0504. doi:10.7326/M20-0504
- Spinato G, Fabbris C, Polesel J, et al. Alterations in Smell or Taste
in Mildly Symptomatic Outpatients with SARS-CoV-2 Infection.JAMA. Published online April 22, 2020.
doi:10.1001/jama.2020.6771
- Vetter Pauline, Vu Diem Lan, L’Huillier Arnaud G, Schibler Manuel,
Kaiser Laurent, Jacquerioz Frederique et al. “Clinical features of
covid-19”BMJ 2020; 369 :m1470
- Bai HX et al., “Performance of radiologists in differentiating
COVID-19 from viral pneumonia on chest CT” Radiology. 2020 Mar
10:200823. doi: 10.1148/radiol.2020200823. [Epub ahead of print]