Patient with COVID-19 who has no specific onset symptoms and progresses rapidly to death: a case report

Since its outbreak, COVID-19 has continued to spread rapidly more than 3 months, which constituted a public health emergence worldwide. The onset symptoms of patients with COVID-19 are not specific, especially in non-respiratory symptoms, it is easy to be ignored, which can cause widespread infection. For critically ill patients, glucocorticoids are used for anti-inflammatory treatment. However, after the application cycle recommended by the guidelines, the deterioration of the patient's condition and treatment to suppress cytokine storms is more critical.

On 27 January 2020, a 62-year-old-woman went to the hospital for diarrhea and abdominal pain without fever or cough. She was only diagnosed with colitis and mild hypertension with blood oxygen saturation (SaO 2) of 80%. A chest CT examination is required for epidemiological screening which showed that the predominant pattern was bilateral lung involvement, ground-glass opacity with illdefined margins. With a nasopharyngeal swab test for confirming, she was transferred to infectious disease hospital. Her vital signs were normal on admission only with diarrhea and abdominal pain accompanied by black loose stool without fever. The clinical symptom and laboratory tests from admission to death are presented in Figure 1and Additional file 1 respectively.
At 14:12 on 4 February, the patient had chest tightness and asthma. Chest CT showed multifocal and ground-glass opacification in both lungs.
Though symptomatic supportive therapy was administered, the patient's condition was aggravated increasingly. Consultation blood gas analysis showed acidosis and hypokalemia with 60 mmHg arterial oxygen tension (PaO 2 ). Give methylprednisolone sodium succinate 40mg intravenously as antiinflammatory treatment for the first time. To prevent respiratory failure, the patient was moved to the Intensive Care Unit (ICU) with noninvasive ventilator to assist breathing. Intravenous infusion of methylprednisolone sodium succinate and atomization of budesonide aerosol are used for antiinflammatory, moxifloxacin for antibacterial, oral antiviral drugs and other nutritional support symptomatic treatment.
At 10:35 on 6 February 2020, the patient had a shortness of breath with 40 breaths/min, SaO 2 of 91%, 4 and plasma potassium concentration of 2.6 mmol. Chest X-ray ( Figure.2A) showed bilateral lower lobes most severely affected. Doxofylline injection was used to relieve cough and asthma and human immunoglobulin injection to enhance antiviral effect. The vital signs were closely monitored and the dyspnea lasted for three days until 10 February and glucocorticoids are gradually reduced after 7 days of application. Chest X-ray (Figure2B) showed a decrease image and signs were basically stable.
We flexibly adjusted the autonomic breathing parameters of the ventilator and reduce the dosage of methylprednisolone gradually. The rest symptomatic treatment was the same as before.
However, the patient got a fever of 37.5℃ in the morning On February 14, 2020. At night, she recurred dyspnea with the frequency of 45/min, and the SaO 2 of 60%-75%. The next day, though the patient had a clear mind, noninvasive ventilation did not ease the difficulty of oxygenation.
Endotracheal intubation was performed and the ventilator was connected to support her breathing and patient was sedated and analgesic. Vital signs are temporarily normal. Right femoral vein catheterization was performed for invasive BP monitoring. After high parameter support and high concentration oxygen supply, the SaO 2 still fluctuated in the range of 60%-75%. Prompt treatment and urgent examinations was given to face the disease progression. On February 16, 2020, chest Xray (Figure2C) examination showed lesions deterioration with larger diffuse distribution compared with the last one. The next day, she was ventilated in prone position in a state of sedation and analgesia. Physical examination revealed deep coma though noradrenaline was continuously pumped intravenously. She continued to have respiratory failure and shock. On February 18, 2020, the patient had a sudden drop-in heart rate at 01:00. Endotracheal intubation and continuous ventilator assisted respiration in Synchronized Intermittent Mandatory Ventilation (SIMV) mode was conducted. Her condition deteriorated at 07:10 with ventricular fibrillation, so adrenaline and electric defibrillation was performed for cardiopulmonary resuscitation. At 07:30, the patient was dead finally.

Discussion
This patient has a relatively younger age with diarrhea and abdominal pain as the first major symptoms, which can easily be ignored and misdiagnosed as acute gastroenteritis causing a wider range of exposure. Her symptoms of diarrhea and abdominal pain were quickly controlled due to antiviral and antibacterial applications. However, the pulmonary infection was serious, and hypoxia developed rapidly though oxygen-inhalation continues. To reduce the inflammatory exudation of pulmonary interstitium, methylprednisolone was used and the symptoms were slightly controlled on the 9th day of her hospitalization. Following the guidelines, we gradually reduced the level of glucocorticoid after 7 days of application.  the Patient's husband. A copy of the consent form has been provided as an "Additional file 2", which is available for review by the Editor of this journal.

Availability of data and materials
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Competing interests
The authors declare that they have no competing interests.

Funding
We declare that the article is not internally and externally funded. LF also participated in drafting the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. All the authors have read and approved the final manuscript.

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