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 However he was started on broad-spectrum anti-microbial drugs to cover any superseded infection in severe COVID 19 patient .i.e. Meropenem, Vancomycin and anidulafungin as per the recommendations of the infectious disease (ID) specialists.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.