Case 2
A 67-year-old female with a history of type II diabetes mellitus and
systemic hypertension developed respiratory distress and was evaluated
in the emergency department. Respiratory rate was 36/min, temperature
37.5 ˚C and oxygen saturation 65% on room air. Upon physical
examination, coarse end-inspiratory crackles were noted at both lung
bases. Chest X-ray showed bilateral airspace opacities, and diffuse
ground-glass opacity was also found in spiral chest CT scan. Laboratory
findings revealed leukopenia (4,200 per mm3), lymphopenia (800 per mm3),
normal platelet (160,000 per mm3) and hemoglobin level
(13.7 g/dl), high CRP (70 mg/l), LDH (840 IU/L), D-dimer (976 µg/ml),
whereas PT, INR, and PTT were in the normal ranges. Nasopharyngeal
sampling was positive for SARS-CoV-2 using real-time PCR method. She
required endotracheal intubation because of no response to oxygen
therapy. Sedatives and neuromuscular blockade were used to enforce a
lung-protective low-stretch strategy. Her treatment was started with
chloroquine 300 mg twice daily on the first day, followed by
Lopinavir/ritonavir 400/100 mg twice daily. Other prescribed drugs
included methylprednisolone, prophylactic unfractionated heparin, and
antibiotics. On 9th day of mechanical ventilation, in spite of the
improvement in oxygenation and decrease of positive end-expiratory
pressure (PEEP) pressure, the patient developed terminal cyanosis in all
fingers of her hands, and a lack of pulse in both radial arteries. Blood
pressure decreased, after initiating the therapeutic dose of heparin and
fluid therapy, she had a radial artery pulse in the left hand without
any improvement in acrocyanosis. One day later she developed
subcutaneous emphysema in her chest, breasts, and face, and finally,
passed away.