Case report
The patient was 28-year old women with no history of any significant co-morbidities. She had a history of contact with COVID-19 cases, but no history of travel outside Dhaka or other country for last six months. Her relative was diagnosed as COVID-19 on 24th June, 2021 with whom she lives. On June 26, 2021, the case felt a mild cough followed by blood in cough one time. As her family history was positive, she went for testing for RT-PCR for SARS-CoV-2 and became positive on 28thJune, 2021 and was in isolation at home and in addition, the dengue RDT, Ag NS1 (ICT) was negative. Her symptoms included dry cough, sore throat, fever (100°F) and shivering at night. She had hemoptysis for two times on June 28, 2021, which consisted of scanty amount of blood. On the next day she had fever (highest body temperature 102°F), with dry cough constantly, sore throat followed by fatigue. She monitored her vital signs regularly and her oxygen saturation was 98-99%. Routine blood tests such as, complete blood count, serum creatinine, D-dimer, serum ferritin done and test results were normal (Table 1). Her chest x-ray also revealed no abnormalities. The patient started medications from June 29, 2021 which included Paracetamol 500mg 1tab 8hourly, Azithromycin 500mg once at night, Montelukast 10mg once at night, Desloratadine 10 mg once in the morning and Multivitamin once in the morning.
On 30th June 2021, physical examination indicated normal vital signs. On auscultation of the lungs, a vesicular breath sound was heard, along with bilateral basal coarse crepitation. There was sign of red rash without itchiness on both upper limbs of the body. Then again on 6th July, investigations were conducted; laboratory reports showed hemoglobin 11.5L g/dL, lymphocyte count 23.2%, neutrophil 72.3%, total leucocyte count 5.13L x 10^ 9/L, red cell count 4.40 x 10^ 12/L, mean cell hemoglobin 26.1 pg, platelet count 175 x 10^ 9/L and dengue IgM was positive, CRP was 0.34. On 6th July mild respiratory distress occurred with dry cough and she was given Salmeterol Xinafoate and Fluticasone Propionate (25/125) two times a day and Deflazacort 6mg started 2-tab 8 hourly.
Thoracic computed tomography (CT) done on 6th July, 2021 revealed subtle ground glass and consolidative opacities were noted in different segments of both lungs, predominantly in a peripheral location with basal distribution, nearly 30% of lung involvement was present. Also sub centimetric mediastinal lymph nodes was also present (Figure 1). These findings were reported in accordance with alveolar hemorrhage.
On 8th July 2021, the patient was in moderate respiratory distress. Her temperature was 100 °F, blood pressure 120/70 mmHg, pulse rate 96 bpm (regular) and oxygen saturation on pulse-oximetry 92-95 % without oxygen. Basal crepitation was found on lung auscultation. She was admitted to the Green life medical college hospital, Dhaka for respiratory distress. Then she was immediately started on stat dose of Remdesivir 200mg IV, Hydrocortisone 100mg 8 hourly, nebulization with Ipratropium Bromide plus Salbutamol 8 hourly, Montelukast 10mg at night, Paracetamol 500mg as required, Moxifloxacin 400mg once at night. She did not require any oxygen during hospitalization. On 9th July 2021, the patient was stable with ongoing treatment and her blood and urine culture, both reports revealed no bacterial growth and her oxygen saturation 95%-98%. On the 10th July 2021, she was discharged from hospital in a relatively stable condition, with the above-mentioned drugs and advice of respiratory exercise. Hemoptysis was her first symptom on June 26th, and she experienced twice the next day, in the morning and at night. Actually, this patient was treated at home initially from June 29 to July 7, 2021 and she had self -medication at home. Also due to the red rash, a dengue test was again performed on July 6, 2021 and the results were positive for dengue IgM. Then on the 8th July 2021, she was admitted to the hospital, and on the 10th July 2021, she was discharged. On July 15, 2021, she recovered and became symptom-free. During follow-upon July 29,2021, a chest CT revealed full clearance of the ground glass opacities, and an RT PCR of a nasopharyngeal swab for SARS-CoV-2 was negative, indicating that her clinical condition had improved There was no further occurrence of hemoptysis after recovery from COVID-19.