Case Report
A 46-year-old male patient, who is not known to have previous chronic medical conditions, presented to the emergency department complaining of feeling of hotness, cough, and loss of smell of 4 days duration. On presentation, he was conscious, alert, and oriented to time, place, and person. He was febrile (Temperature of 38.9 C°), tachycardic with heart rate of 104 bpm, tachypnoeic with a respiratory rate of 28 breaths per minute, Blood Pressure was 107/81 mm Hg and O2 saturation on room air was 97%.
On physical examination, pupils were equal in size and reaction to light. Chest auscultation showed clear breath sounds bilaterally with normal S1S2 and no murmurs. Abdomen was flat, soft, with no tenderness or guarding. Extremities: no bipedal enema, bilateral full and equal pulses. GCS 15/15, no neurologic deficits.
Blood investigations revealed WBC to be 5.7×109 L, with low lymphocytic count 0.7*103 uL Haemoglobin 15.3 g/dl, platelet count 122×109 L, Urea 3.04 mmol/l, creatinine 89 umol/L, CRP 140 mg/L, and normal electrolytes.
Chest x-ray demonstrated multiple pneumonitic patches seen in both lung fields which were suggestive of viral pneumonia. Nasopharyngeal swab for COVID-19 PCR was positive. Based on the above-mentioned work up the patient was admitted as a case of COVID-19 pneumonia. His condition deteriorated the next day of admission, and he was more tachypnoeic requiring O2 supplementation by nasal cannula.
He was transferred to Medical intensive care unit (MICU) for observation. As his oxygen requirements increased, he was started on none rebreathing mask (NRM) then switched into non-invasive ventilation (CPAP). Despite this, his condition deteriorated further that required endotracheal intubation and he was started on mechanical ventilation.
He received a treatment protocol for COVID-19 infection according to our hospital protocol in accordance with the international guidelines at that time, which was as the following:
1-Hydroxy-Chloroquine 400 mg once daily X 10 days
2-Azithromycin 500 mg X 7 days
3- Methyl prednisolone 40 mg IV q12hr for 5 days.
4- Tocilizumab 600 mg IV 2 total of 2 doses (8 days between the 2 doses)
He was kept on enoxaparin for DVT prophylaxis, and the dose was adjusted according to his clinical situation with monitoring of Anti Xa. Furthermore, he received convalescent plasma.
During this time, the platelet counts had dropped to as low as 92*103 for 2 days then improved to normal levels. The INR was normal, and heparin induced thrombocytopenia (HIT) test was negative. No noticeable overt bleeding episodes.
He was kept on mechanical ventilation and the ventilator setting was adjusted. Proning was required three times and his condition was gradually improving. Sedation and muscle relaxation were tapered off and after 18 days he was successfully extubated.
After extubation, the patient was unable to move his four limbs, but he had intact level of consciousness. Physical examination revealed a power of 1/5 in all muscle groups of upper and
lower limbs, bilateral lower limb wasting with hyporeflexia, no fasciculations, plantar reflex was negative, and sensation was intact.
As an evaluation of his quadriplegia, brain& spinal cord MRI (Figure1) were done and showed late subacute hematoma involving the corpus callosum, with a background of numerous supra and infratentorial foci of microbleeds. Cervicodorsal spinal cord MRI was unremarkable. Accordingly, enoxaparin was stopped on the same day.
Neurosurgery team was consulted regarding any possible therapeutic intervention for the subacute callosal hematoma. Since the hematoma was not causing any mass effect and the fact that it was subacute with no associated IVH, no neurosurgical intervention would be of benefit.
Neurology team evaluation was suggesting critical illness neuropathy/myelopathy as a cause of the quadriplegia rather than the hematoma itself. Due to isolation precautions nerve conduction study nor electromyography could be done.
Next day, he was noted to have persistent tachycardia with HR ranging 100-120 BPM. CT pulmonary angiogram (Figure 2) was done and showed two pulmonary thromboembolisms. The pulmonary thromboembolism involved the anterior branch of the left main pulmonary artery extending to sub-segmental branches and the posterior basal segmental and sub-segmental branches of right lower lobe pulmonary artery.
Considering the intracranial bleeding, he was commenced on heparin infusion with close monitoring of the neuro vitals. Then, he was switched into therapeutic low molecular weight heparin. Follow up head CT scan (Figure 3) demonstrated the same subacute corpus callosum hematoma, with no acute changes or bleeding.
COVID-19 PCR swab was repeated twice and both results were negative.
Patient was tapered off O2 supplementation and he maintained an acceptable O2 saturation on ambient air.
After discussing the case with haematology team, with consideration to the patient condition, the patient was given therapeutic dose enoxaparin subcutaneously for 3 months as a case of provoked pulmonary thromboembolism.
Extensive physiotherapy sessions were started with gradual and noticeable improvement in the muscle groups power.
Patient was being treated as an inpatient for 2 months, then continued physiotherapy in rehabilitation institute for another 1 month. On discharge, muscle power was 4/5 & he was independent in most of the activities of daily living, with need for assistance in using stairs only.
On further follow up, patient continued to attend outpatient physiotherapy sessions on weekly basis. He completed 3 months enoxaparin for anticoagulation, no reported bleeding episodes.
The Patient is now functioning independently, and he returned to his work.