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.