Case Summary:
A 50-year-old hypertensive Filipino gentleman presented to the emergency
department (ED) with a one-week history of dry cough associated with
high-grade fever, fatigue, and myalgias. His vital signs showed
tachypnea around 22-26/min, tachycardia with a heart rate of
103-110/min, a blood pressure of around 175/112 mmHg, and desaturation
requiring 10l/min non-re-breather mask (NRM) to maintain o2 saturation
of around 86-88%. He was tested positive for COVID-19 PCR from a
nasopharyngeal swab. His chest XR revealed bilateral infiltrates
predominantly in the lower zones (Figure 1). CT pulmonary angiogram
(CTPA) ruled out PE but showed bilateral ground-glass attenuation of the
upper lobes, and bilateral lower lobes segmental consolidations with
bronchogram. His overall clinical picture was suggestive of severe
COVID-19 pneumonia leading to acute respiratory distress syndrome
(ARDS). He was being treated based on local guidelines however his
condition deteriorated on the 6th day of hospital
stay, with an increase in respiratory distress. He was having tachypnea
at around 40/min and was kept on non-invasive ventilation with
continuous positive airway pressure (CPAP) ventilation. He was shifted
to an ICU facility. He did not improve and was intubated and
mechanically ventilated on the 8th day of his
admission. He was spiking fever and there was a rise in his inflammatory
markers concerning for a cytokine storm. Septic workup did not reveal
any microorganism growth or any source of infection. However he was
started on broad-spectrum anti-microbial drugs to cover any superseded
infection in severe COVID 19 patient .i.e. Meropenem, Vancomycin and
anidulafungin as per the recommendations of the infectious disease (ID)
specialists. His Pao2 was not improving, even after proning him multiple
times and giving him inhaled nitric oxide. Therefore, the decision to
commence the patient on veno-venous extracorporeal membrane oxygenation
(V-V ECMO) was made on the 16th day of his admission.
CT thorax did not reveal any pulmonary embolism or barotrauma. However,
it redemonstrated the bilateral ground-glass opacities (Figure 2). The
patient’s hospital course improved initially, and he was extubated on
the 25th day of his admission and antibiotics were
ultimately stopped after the completion of their course.
On the 31st day of admission, he was re-intubated due
to tachypnea and abnormal paradoxical breathing pattern. Initial chest
XR showed new lung infiltrates in the left upper zone. Bronchoscopy and
subsequent bronchoalveolar lavage fluid cultures were negative. Blood
cultures grew Enterococcus faecalis and sputum cultures grew Klebsiella
pneumonia. He was given a course of antibiotics according to the
sensitivities of the cultures. On the 39th day of
admission, the patient was tracheostomized due to a prolonged course on
mechanical ventilation. The patient had fluctuations in his GCS,
drowsiness, intermittent fever spikes, rise in inflammatory markers and
was difficult to wean off from high oxygen settings. Septic workup was
repeated including blood cultures, urine culture, TB work up, tracheal
aspirate cultures, BAL fluid cultures and respiratory viruses including
CMV, EBV and adenovirus PCR. His urine and BAL cultures grew Candida
Albicans sensitive to Fluconazole. Furthermore, the BAL cultures and
blood cultures were positive for CMV. He was started on Ganciclovir with
weekly CMV PCR. His condition improved and was de-cannulated off ECMO.
His GCS stabilized and he was able to open his eyes and follow simple
commands. The patient was then followed with repeat CMV PCR viral counts
to optimize the anti-viral therapies according to the ID specialists.
The trend of CMV PCR viral load is shown in figure 3. On follow up, the
patient in under physical and occupational therapists to help with
critical care myopathy.