At 09:00 on February 15, 2020, a 68-year-old man consulted an emergency physician in the First Affiliated Hospital of Zhengzhou University for a 10-day abdominalgia and a 6-day cough accompanied by objective fever (the highest axillary temperature was 39.1°C). He presented with a mask and disclosed that he had come from Xinyang, Henan Province, China, which is the most severely COVID–19-affected city in Henan province. However, our patient did not admit having traveled to Hubei Province or having direct contact with the people who came from Hubei Provence and denied having any history of hypertension, diabetes mellitus, cardiovascular disease, tuberculosis or hypertriglyceridemia. He told the doctor that he had smoked for most of his life but had always been healthy.
A physical examination found an axillary temperature of 38.5°C, pulse of 106 beats per min, respiratory rate of 27 breaths per min, blood pressure of 159/85 mmHg, and oxygen saturation of 98% when the patient was receiving 3 L/min of oxygen via nasal prongs; the oxygen saturation value dropped below 92% when he was breathing ambient air.
Considering that the patient had come from the most severely infected area in Henan Provence, nasopharyngeal swab specimens were collected as routine, and pathogens, including influenza A and B, were tested for. Then, this patient was isolated in the emergency ward. Lung auscultation revealed diminished sounds and moist rales. The lab results were returned as negative for influenza A and B at 09:28, while nasopharyngeal swabs tested positive for COVID–19 by rRT-PCR at 16:40 the same day. The patient was immediately transferred to the isolation ward.
The patient complained of a 10-day history of consistent abdominal pain, which was accompanied by constipation. He did not report nausea and was not vomiting, but he could not clearly describe the precise position or character of the abdominal pain. He reported that he had malaise with breathing, and that he had sometimes coughed up white mucus during the past 4 days. Vital signs showed fever, tachypnoea, tachycardia, and raised blood pressure. At 19:27, the chest computed tomography (CT) and contrast-enhanced CT detected bronchitis, emphysema, and thoracic aorta aneurysm (Figures 1, 2), but no particular abnormality was observed in the abdomen.
CT scan imaging identified diminished transparency of the lung and fuzzy margins, consistent with COVID–19, but no specific manifestation. As there is no specific treatment for COVID–19, therapy mainly consisted of symptom control. To deal with fever, the patient received 900 mg of aspirin-lysine by intramuscular injection once. He also received 300 mg doxofylline once by intravenous drip to treat his bronchitis and expectorant consisting of 90 mg of ambroxol once by intravenous drip to manage his white mucus. Sodium nitroprusside (25 mg) was pumped into the drip to control the high blood pressure. Lopinavir/ Ritonavir 400 mg/100 mg film-coated tablets was given twice a day to help controlling virus. Blood tests, blood cell count, and serum chemical tests displayed mild erythropenia, leukocytosis, and thrombocytosis (Table 1). CT imaging indicated pneumonia, and clinical symptoms and blood counting suggested that bacterial pneumonia might also be present. Based on these findings, 400 mg of moxifloxacin once per day and 3 g of sulperazon every 8 h were administered. Our patient was consistently supplied with oxygen by nasal cannula at 3 L per minute to maintain an oxygen saturation of around 98%. The measurement of hepatic function revealed an albumin (Alb) level of 25.3 g/L, globulin (Glob) level of 43.4 g/L and cholinesterase (Che) level of 3.00 KU/L (Table 1). At 23:21, the patient’s procalcitonin (PCT) level increased to 1.340 ng/mL (reference range between 0–0.046 ng/mL), C-Reactive Protein (CRP) level increased to 215.04 mg/L (reference range between 0–5 mg/L), and interleukin 6 (IL–6) level increased to 156.80 pg/mL (reference range between 0–7 mg/L).
The patient was under continuous electrocardiographic (ECG) monitoring after being admitted to the isolation ward. This patient disclosed that he felt better after supportive treatment given by his doctors. On February 16 at 03:10, the patient’s condition rapidly worsened; the monitor alarmed that the blood pressure and heart rate of the patient could not be detected. The patient lost consciousness and had no response to his doctors’ call. The patient had no bilateral pupillary light reflex and carotid artery pulse. In this
emergency, doctors placed the patient in a prostration position without a pillow and immediately performed cardiopulmonary resuscitation (CPR). Adrenaline (1 mg) was given every 3 minutes by intravenous injection, and 180 mg dopamine was pumped in to increase heart rate and blood pressure. Intubation was operated by the doctors wearing appropriate protective equipment. An ultrasound technician and a vascular surgeon were invited for consultation. The chest ultrasound at our patient’s bedside presented extensive pleural effusion, which did not show up by CT, and the doctors reached an agreement that the patient’s aorta had ruptured. The patient’s vital signs did not recover despite the rescue measures. A flat line was seen in the ECG monitor. At 04:12 on February 16, within 19 h of hospital admission, the patient was pronounced dead.