In 8 March 2020; a 61 years old woman, citizen of Tehran city, who is married, 60 Kg weight, temperature at admission 38° C, RR 18 per min, PR 82 per min and blood pressure 130/80 mmHg. The main complaint at admission was coughing and fever. She has a history of diabetes, hypothyroidism, osteoarthrosis and hypertension and went under angiography with implanted stent in her heart. It worth to mention that she is not allergic to any drugs nor food. Echocardiography and ECG had no pathological evidence.
On the first day of admission, she had discomfort in chest wall and she mentioned she had white sputum since 10 days ago. She was suspicious of COVID-19. Blood tests revealed: ESR 81 mm/h; CRP 3+; urea 39 mg/dl; FBS 221 mg/dl; AST 45 mg/dl; ALT 19 mg/dl; PT 12.5 sec; PTT 39 sec; LDH 432 IU/L; BP 130/80 mmHg; temperature 37.4° C. She vomited after having dinner on 19.55 pm. She took 150 cc N/S; diphenhydramine and ondansetron. In summary, she had nausea, sputum, fever, the symptoms had been strengthen in 10 recent days. The CT imaging (Figure 1) showed pleural effusion with grand glass involvement.
Blood tests on 9 March revealed, calcium 8 mg/dl; phosphorus 3.5 mg/dl; WBC 3.6*103/µl; RBC 4.17*106/µl; Lymphocyte 22.4%; Neutrophil 64.3%; vitamin D3 32 mg/dl; LDH 432 IU/L. Additionally, blood culture was done on next day and the results showed no growth after 48 hours.
In 11 March, blood tests revealed FBS 161 mg/dl; LDH 427 IU/L. The assessment of pleural fluid revealed: 5.4 protein in fluid; 4.8 Albumin; glucose 143; PH 8, and cell count revealed 900 RBC and 1700 WBC, 1.5 % neutrophil and 85 % lymphocytes, furthermore, mesothelial cells have been seen. Pleural direct smear results showed no bacteria. Pleural fluid C & S showed no growth after 72 hours. 30 cc serous fluid with clear yellowish appearance has been taped from left pleural space under the guide of sonography.
In 16 March, 100 cc fluid has been seen in left pleural space and 40 cc of clear yellowish appearance fluid has been taped under the guide of sonography. The microbiology test results of assessment of pleural fluid revealed no acid-fast bacilli per 100 fields and WBC 4-5. ADA 19 U/L.
The FBS assessment during our treatment procedure (Table 1) and the clinical symptom report during our treatment procedure (Table 2) are shown in tables 1 and 2.
The results of pleural fluid tests in comparison to serum LDH and serum protein amounts, showed that the pleural fluid nature was exudative with lymphocyte preference, this result rules out the possibility of appearance of pleural effusion due to other heart problems. The tapped pleural fluid had no empyema properties, therefore there was no need for fluid discharge by chest tube.
2-1. PCR test for corona COVID-19 came positive
The duration of drug admission is twelve days, and her fever fade away on the day 4. The treatment she received includes oseltamivir (75 mg) every 12 hours for 5 days from the first day of admission; Hydroxychloroquine (200 mg) every 12 hours for 5 days from the first day of admission; Ceftriaxone (1 g) every 12 hours and Clindamycin (600 mg) every 6 hours for the duration of one week from the first day of admission (for pleural effusion); and Oxygen therapy with mask. Symptomatic treatments included antipyretic (48 hours) and antiemetic (48 hours). Clindamycin has been stopped from the seventh day due to the appearance of diarrhea.
Kaletra (Lopinavir 200mg / Ritonavir 50mg: 2 times a day) 400/100 was used for the duration of 5 days every 12 hours from the first day of admission.
It should be mentioned that her previous drugs for diabetes, hypertension and heart problems continued as before. She received metformin and zipmet for diabetes and metoral, losartan and atorvastatin for cardiovascular disease. After endocrinology consultation, diabetes medicine was changed to melijent.
Fortunately, in spite of multiple underlying diseases and the first report of pleural effusion in our entire patients, she had good appetite without fever in 11th day of admission. Finally she discharged on 19 March with good general condition and O2sat of 95%. The patient was advised to quarantine herself at home for two weeks.