However, he comes back to us two days later with
persistence of his initial presenting complaints,
but his cough is now worse - still not
productive but he's finding it difficult to breath
both with tightness of his chest and also
shortness of breath associated with the coughing.
He now has even more pronounced
anorexia, he’s lost his appetite completely.
Still no other GI symptoms and still no
new complaints other than as noted above.
His examination continues to demonstrate a highly febrile
adult male who is still tachycardic, even more tachypneic.
And now without even changing his medications,
his blood pressure, if anything, is low.
So, we now have a patient who has become
hypotensive which is definitely a cause of concern.
This time, we remember to do our
spot check for his peripheral oxygenation
and indeed he has an
oxygenation of only 89% on room air.
This is cause for concern regardless of the viral
etiology but certainly if we're considering COVID-19.
This would be a trigger for us to do a
further evaluation and further intervention.
His chest exam now demonstrates
diffuse fine crackles bilaterally.
His air entry is adequate but not great and
he does show increased work of breathing.
The rest of this exam however is unchanged.
So again, what should leap out at us is the
worsening of symptoms especially the cough,
the development of shortness of breath and an associated
decreased peripheral oxygenation of less than 90%.
These are two red flags for
COVID-19 suspect patients
that would significantly suggest a need to
do further intervention and further evaluation.
Similarly, he now has evidence of hypotension
which could be a complication of advancing COVID-19
or of a potentially superinfection from
a viral etiology with bacterial sepsis.
So long story short, Mr. Lecturio
has got our concern or interest
and we need to consider what to do next.
So, what are next steps in the assessment?
If we haven't already, we'll
certainly wish to evaluate
for other viral etiologies and
consider now testing for COVID-19,
given again the fairly nonspecific
nature of presentation for all of these,
Mr. Lecturio could still have any one of the etiologies
you see listed on the screeni n front of you -
any of the influenzas, parainfluenza, rhinovirus,
coronavirus, COVID-19 disease, anything else.
What are the next steps?
Do we now consider testing?
what we do next?
And in fact, we may wish to
consider doing blood testing
along with testing specifically for
COVID-19 and also considering imaging.
What are we gonna see with
these in the setting of COVID-19?
CBC - we're looking especially for either a normal or
potentially reduced peripheral white blood cell count.
So leukopenia, along with a lymphopenia
- reduced percentage of lymphocytes
and maybe even in some cases, about 40% so
far, thrombocytopenia - decreased platelet count.
The inflammatory markers, we're looking
to see an elevated C-reactive protein or
creatine kinase and elevated lactate
Something suggest that there is cytokine
storm and/or inflammatory burst occurring
as these are highly associated
with advancing disease in COVID-19.
Organ function - we absolutely
want to see where is kidneys are at,
where his liver is at,
where his heart is at.
So doing a comprehensive metabolic panel
to include signs or indicators of kidney function,
liver function, liver numbers and
then sending cardiac enzymes.
All of which are indicated.
Doing a blood gas - if we want to
confirm our lower peripheral oxygenation
and see is he indeed failing to
exchange oxygen and carbon dioxide?
What is his pH? Do we have respiratory
acidosis? alkalosis? etcetera.
Sending a blood culture, well yes because even
if this is COVID-19 or other viral etiologies,
there's still could be the potential
of a secondary bacterial infection.
Yes, we want to consider COVID-19 testing
because we now wish to do further emergent care.
Mr. Lecturio requires help and we
need to know if he is a suspect patient.
Then imaging, considering chest radiograph
versus computed tomograpy or CT scan.
Of the two, the CT scan will be
more specific and sensitive for findings
that we wish to demonstrate
in the setting of COVID-19.
Chest radiograph, however is easier to obtain,
easier to perform and thus may be the first step
while we're contacting the radiology
suite to get our next set of testing.
So, in this case, with the anticipated
results as we just discussed,
Mr. Lecturio's results start to come back.
And indeed, his complete blood count shows a low
white blood cell count of 2.7 or 2700 cells per mm3,
with 67% neutrophils, 25%
lymphocyte and 5% monocytes.
So indeed, he now is leukopenic
and definitely lymphopenic.
His hemoglobin/hematocrit are normal but
he is thrombocytopenic at 85000 (per mm3).
His inflammatory markers demonstrate slight
elevation of the C-reactive protein with 4.7 (mg/L),
normal being less than 3 (mg/L)
and his lactate dehydrogenase
is also slightly elevated at 360 (U/L).
Moving on then to his organ function.
Indeed he shows evidence of some early
renal insufficiency with a slightly elevated
blood urea nitrogen at 24 (mg/L)
and an elevated creatinine of 1.4 mg/dL
In addition, his transaminases AST and
ALT are 85 (U/L) and 79 (U/L) respectively,
although his total bilirubin is normal and
his troponin I is slightly elevated at 0.5 ng/mL.
So he has evidence of a mild
multiorgan disease which will go along with
potentially invasive bacterial sepsis, a SIRS -
a systemic inflammatory response syndrome
but also with multiorgan dysfunction
syndrome which can be seen
with more advanced or
severe COVID-19 disease.
His blood gas obtained from an arterial
source shows a slightly elevated pH of 7.47,
a low partial pressure O2 of 55 mmHg,
partial pressure of CO2 of 32 mmHg,
and his bicarb (HCO3) is in
the normal range of 25 mmol/L.
By then and again, his peripheral
oxygenation is low now at 87%
He has a blood culture is sent in this case to
look for a bacterial superinfection or pathogens
and is negative at 48 hours which suggests
- it doesn't exclude - but it does suggest
that there is no bacterial
superinfection at this stage.
Chest radiograph indeed was performed,
just because it was easier and faster to obtain
and it showed the typical nonspecific
bilateral infrahilar airspace opacities.
which could be seen in any viral process
or even in nonspecific atelectatic changes.
However, there's no evidence of increased
fluid because the costovertebral angles are clear.
A chest CT scan though does
demonstrates bilateral nodules
and the expected peripheral ground
glass opacities throughout the lung fields
as well as some mild
interlobular septal thickening.
All these can be seen in COVID-19
disease, and also to a significant extent
in acute respiratory distress syndrome
(ARDS) caused by a variety of pathogens.
So where are we at then?
What are the ultimate diagnoses?
In Mr. Lecturio's case, rapid testing
for influenza came back negative
as did molecular diagnostics
for other respiratory virus panels.
This does not completely exclude those
diseases but it makes them less likely.
However his nucleic amplification assay is positive
for the SARS-coronavirus-2, the cause of COVID-19.
So we can make a strong
presumptive diagnosis of COVID-19
Knowing however, that
coinfection is still possible
especially with influenza and also
potentially bacterial superinfection.
So this case presentation shows a typical progression
and typical findings for an advanced case of COVID-19.
However which began with mild disease
and you can see, I hope you can see that
it's very difficult to differentiate
COVID-19 caused by SARS-coronavirus-2
from other viral pathogens causing
upper and lower respiratory tract infections.
However, hopefully this case is instructive
in looking at how a patient may progress
and ultimately come to medical
attention and deserve further evaluation.
Now, looking specifically again what
I shared with you with Mr. Lecturio,
What is his risk of critical disease?
Looking at his age, age 62, well so an age
of 65 has been looked at as a strong cutoff,
above which a risk of critical
disease is quite significant.
However the risk begins to
escalate even in the late 20s.
So age 62 would be a moderate
risk factor for risk of critical disease.
However, in specific to this case, Mr. Lecturio
does have two comorbidities,
that being hypertension and diabetes mellitus,
both of which increases risk for severe disease,
Further when he represented to us the second
time, the peripheral oxygenation was less than 93%
He also had elevations of his transaminases
and worsening of his renal function.
So he has multiorgan dysfunction, some hypotension,
definitely a difficulty in air exchange in oxygenation
and an impending hypoxic respiratory failure.
So, Mr. Lecturio's risk of critical
disease is actually quite extensive
and this case would suggest one who definitely
deserves hospitalization, close monitoring,
and further support as necessary.
So to wrap things up, starting
from a mild, nonspecific illness,
yet with risk factors which we've
identified and also with comorbidities,
this case shows a very unfortunate but typical
progression into much more severe critical disease,
along the way being differentiated from
other viral pathogens which may contribute to
or cause instead of the disease which
we're looking at as caused by COVID-19.