Case Presentation:
A 53-year-old gentleman with a past medical history of diabetes
mellitus, hypertension, and dyslipidemia, presented to the hospital with
one day history of dyspnea. He was treated for COVID-19 pneumonia and
was discharged one day prior to his readmission. His initial
presentation was with dyspnea, fever, fatigue, and a dry cough.
Investigation revealed a positive SARS-CoV-2 reverse transcription
polymerase chain reaction (RT-PCR) with bilateral infiltrates on Chest
Xray (CXR) [Figure 1a].
Initially he required 3-4 L of oxygen to maintain saturation, but the
requirement increased in the subsequent days and reached up to 13 Liters
of oxygen via non-rebreather (NRB) mask. He was treated with favipravir
and dexamethasone for 10 days, according to the local guidelines at the
time. The patient gradually improved, and his oxygen requirement
decreased. He was discharged from the hospital in an asymptomatic
condition, saturating 100 percent on room air. His repeated SARS-CoV-2
RT-PCR as negative.
One day after discharge, the patient presented with a new onset
shortness of breath at rest and exertion. He was requiring 2-3 Liters of
oxygen to maintain saturation (SPO2) above 94 %, and
was tachypneic (26 breaths per minute). He was afebrile and did not have
any other symptoms. Chest examination revealed bi-basal crackles, with
rest of the physical exam unremarkable.
A Chest Xray (CXR) was repeated and did not show significant changes
comparing to the previous one [Figure 1b]. A CT pulmonary
angiography showed no evidence of pulmonary embolism. However, it was
significant for extensive bilateral patchy areas of ground glass
opacities and patchy areas of consolidations with air bronchograms
[Figure 2].
He was tested again for COIVD-19, but the RT-PCR result came negative,
ruling out a possibility of reinfection. The sepsis workup did not
reveal any bacterial growth (including Mycoplasma pneumonia, Legionella
pneumophila and Chlamydia pneumonia). Nasopharyngeal PCR for common
respiratory viruses (including Influenza, Parainfluenza, Respiratory
syncytial virus and Middle East respiratory syndrome coronavirus) were
negative. A bronchoscopy performed to rule out tuberculosis (TB),
eosinophilic pneumonia or pulmonary hemorrhage was unrevealing.
As the patient continued to have desaturation, a multidisciplinary team
decided to start a trail of 60 mg prednisolone for 2 weeks. He responded
very well, and oxygen requirement decreased. He was off oxygen at rest
in two days and was discharged with a follow-up in pulmonary clinic.
Repeated CXR after 2 weeks from discharge showed significant regression
on bilateral infiltrate [Figure 1c]. Pulmonary Function Test (PFT)
was done, which showed a restrictive pattern with decreased Diffusing
capacity for carbon monoxide (DLCO) [Figure 3]. A 6 minutes walking
test showed a vivid improvement compared to his previous condition where
was not able to complete more than 3 minutes of walking.