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.