Case Presentation:
A 52-year-old male, with no comorbidities, presented to the emergency
department with a 10-day history
of fever and dry cough followed by progressive, exertional shortness of
breath. The patient is a non-smoker and worked as a driver. Examination
showed a febrile ill-looking patient, in respiratory distress with a
respiratory rate of 36 breath per minute and requiring 6L of Oxygen via
nasal cannula. Chest auscultation was significant for bilateral
crackles, without evidence of raised JVP or lower limb edema. Other
examination findings were within normal parameters. The initial
investigation was significant for WBC – 17 x10^3/uL, CRP – 131
mg/L, Ferritin – 836 ug/L and bilateral pulmonary infiltrates in Chest
X-Ray (Figure 1). COVID-19 rRt-PCR tested positive; hence was diagnosed
with sever COVID-19 pneumonia and was started on ceftriaxone,
hydroxychloroquine, azithromycin, oseltamivir in addition to as-needed
paracetamol. Over the subsequent five days, his oxygen requirements
gradually increased, reaching 11 L via a nonrebreather mask. A follow-up
chest x-ray showed progression of previously seen bilateral infiltrates
(Figure 2).
He was started on methylprednisolone and non-invasive ventilation. Two
weeks into admission, the
patient’s condition continued to deteriorate, and intubation was
required. Two weeks later, the patient started to spike high-grade
fever, with further septic work up revealing pseudomonas aeruginosa and
stenotrophomonas maltophilia in tracheal aspirate culture; hence started
on Piperacillin-Tazobactam and
Teicoplanin. CT thorax was done and revealed bilateral diffuse
ground-glass infiltrates and airspace
involving almost all lung segments (Figure 3).
Over the next few days, the patient was afebrile, however, repeat
tracheal aspirate culture was persistently positive for pseudomonas and
stenotrophomonas maltophilia. Five days later, the patient was
extubated; but was re-intubated due to respiratory distress and
hypoxemia. After multiple failed attempts to wean the patient off
mechanical ventilation, he was tracheostomized and eventually
de-cannulated. The patient was transferred to the medical ward after
staying in the critical care unit for a total of 38 days. The patient
was on room air when admitted to the medicine ward. However, a few days
later, he started to desaturate gradually. Repeated CXR showed diffuse
coarse reticular interstitial changes. COVID-19 rRT-PCR was negative and
sepsis workup was unrevealing. A follow-up CT chest was done for further
assessment, it showed a slight improvement of the diffuse bilateral
ground-glass opacities with re-demonstration of some crazy-paving
appearance at both apical segments of upper lobes and it also showed
progression of the interstitial fibrotic and bronchiectatic changes
predominantly in the anterior aspects of both lungs (Figure 4).The
patient was transferred to a long-term care hospital for oxygen
supplementation, chest physiotherapy, and physical therapy for his
critical care myopathy.