Coronavirus Infectious Disease-19. A clinical case.
So, in this session, we're going to look at a clinical scenario with a case presentation
and use it to examine distinguishing features
which may help us to differentiate infection by SARS coronavirus 2,
the cause of COVID-19 versus other respiratory infections
currently circulating in the world those being: influenza A/B, parainfluenza, rhinovirus,
and even some other typical pneumonias.
At the end of the presentation, we'll also look at what factors precipitate a risk of progression.
We'll start with our case. Mr. Lecturio, of course, this is his history of present illness.
He is a 62-year-old male who comes to us in clinic with fever, cough and malaise for three days.
Importantly, he, two weeks ago was evacuated from a cruise ship
which was approaching Venice, Italy due to a cluster of cases
occurring in that part of that country.
However after arrival back in the states,
he was fine until just three days ago and then presented with these symptoms.
The fever's tactile. He has not measured it.
However, the cough is dry, nonproductive
and he denies any associated chest pain or certainly shortness of breath.
The malaise, very typical flu like illness, so tired, somewhat decreased appetite,
just sort of moping around, feeling not very well.
The major features we should notice here are number one, his age
and the fact that he is a he, he's male.
These are risk factors already emerging in COVID-19
as potentially suggesting more severe advanced disease.
He's had his illness for three days. Not weeks, but three days.
But he also had two weeks ago, an exposure to a known source of COVID-19 disease
via this cruise ship and especially the country Italy.
However, as we look at other infectious disease processes, simply being on a cruise ship,
simply being on vacation are all going to increase risk for other respiratory viral pathogens.
So, none of these are specifically going to delineate COVID-19 as the causative a disease here.
The tactile fever, the cough which is dry, but no chest pain or shortness of breath,
these are all very likely early presentation signs and symptoms for any viral process
as is the decrease appetite and the flu-like process.
Review of systems for Mr. Lecturio, he denies a whole bunch of things.
So, really no upper respiratory tract signs or symptoms like rhinorrhea or congestion.
He denies signs of cardiac dysfunction, so no chest pain, palpitations dizziness or sweating.
He denies prominent G.I. symptoms, so no nausea, vomiting or diarrhea or no abdominal pain.
No rashes to suggest sort of a viral exanthem which might go with other types of viruses.
And no confusion or hallucinations which could go along with,
if not viral illness potentially other psychiatric disorders or even encephalitis or encephalopathy.
And then no decreased urine output.
He denies urine changes which argues against end organ dysfunction so far.
However, he does endorse headache,
a diffused non-specific headache and diffused myalgias and Polly arthralgias.
Past medical history. He does have hypertension which is ostensibly controlled with losartan
which is an angiotensin II receptor antagonist.
He also recently has been diagnosed with type II non-insulin dependent diabetes mellitus
which he claims has been controlled with diet.
Social history, he's a certified public accountant.
Married, with two children -- two adult children.
He had the travel as recently noted and no other known sick contacts or exposures
such as unusual animals or pets or anything like that.
Family history. Also, there were primary family members with hypertension,
coronary artery disease and insulin dependent diabetes mellitus.
So again, what leaps out of this from this additional history?
Is that Mr. Lecturio has two additional comorbidities that being,
hypertension being treated with losartan and a diabetes mellitus.
The certified public accountant. Yes, this might be a high stress position.
We're worried about it more because it means he has extensive face-to-face contact
with a number of his clients.
Which means rather than having no sick contact exposures, he has potential for sick contacts.
Again, that travel history, he had significant potential travel exposure from the cruise ship
and also that part of the world where there is known COVID-19 circulating
as well as other respiratory viruses. And then the family history.
Again, significant for comorbidities which we know are associated
with worst disease or progression of disease with COVID-19.
Physical examination for Mr. Lecturio.
So he indeed is febrile with a temperature of 38.6 degree Celsius.
He is somewhat tachycardic with a heart rate of 98.
And tachypnic with a respiratory rate of 22.
His blood pressure, maybe not as well-controlled
as he thinks it is with the losartan is elevated at 143/92.
The rest of his exam however at this point is normal.
This by the way is very typical for early onset COVID-19 patients
as well as other viral respiratory and upper -- or lower respiratory tract infection patients.
So not much to speak of including the chest exam
in which his lungs have cleared auscultation with good air entry throughout.
So, where are we at? Initial assessment, he does have risk factors
which make us think of higher risk for developing COVID-19 disease
as well as progression to severe disease.
However, his presentation at this point is still very much nonspecific.
It could be anything and everything.
Similarly, his physical examination does not lead us in any one specific way.
So what is our differential diagnosis?
Well, of course, COVID-19 presenting with mild upper respiratory tract infections
and potentially progressing but not yet so far.
Influenza, we know can start with a flu-like illness as noticed.
So fevers, myalgias, Polly arthralgias, general malaise
and this could be all that he feels with influenza or it could progress.
Parainfluenza, typically a cause of croup in younger children
but certainly a cause of a staccato dry cough with respiratory distress in adults
who experience it and with a very prolonged clinical course.
Early-onset symptoms however with parainfluenza just like the first two
I've already discussed can be very nonspecific; fevers, malaise, dry cough.
Similarly, rhinovirus. We all know about the three days coming, three days with us,
three days leaving history of the common cold.
The cough would be a little bit unusual for rhinovirus unless he's having postnasal drip.
Similarly, the malaise, although if he's having a man cold,
he could be experiencing that.
So, this could still be rhinovirus but it's just -- it's a little bit more overt in its presentation.
And then other possibilities; bacterial pneumonias such as atypical pneumonia,
perhaps caused by mycoplasma pneumoniae or Chlamydia pneumoniae
or even some other unusual possibilities,
Legionella for example all acquired via his cruise ship exposure or face-to-face contact
because of his employment; his work.
So, what do we do next? At this stage, does he deserve further evaluation?
Does he deserve further intervention?
And at least from the COVID-19 response, the answer is no.
He has mild disease. He has no distress.
He does have risk factors, but given the current shortage of testing kits
in many parts of the world, it would not be possible I should say
to do formal testing for COVID-19
because the ability with limited testing kits is somewhat reduced.
However, it would be reasonable to consider testing for the other viral possibilities.
So, in nasopharyngeal or oropharyngeal swab just send it for rapid assessment for influenza A,
perhaps other respiratory pathogens on a panel and then let him go home.
A shelter at home, self-quarantine, watch, wait and see what develops.
I will note however, we have one critical lapse in our initial evaluation.
And that is a spot check of his peripheral oxygenation, assessing his SpO2.
Which if it were less than 93% would be a strong suggestion of concern
for progression in COVID-19 and might tip us into admitting him
or at least sending him for further evaluation.
However, we don't have that so at this point, Mr. Lecturio goes home.