In June 2020, a 41-year-old female nursing manager with a history of chronic rhino-sinusitis presented with myalgia, headache and a postnasal drip with no documented COVID-19 exposure. The patient consulted with her local general practitioner (GP) who diagnosed acute sinusitis and prescribed amoxicillin, nasal decongestants and analgesics.
On day 3, the symptom severity escalated however up until this stage no pyrexia was evident. The patient returned to the GP as her symptoms were not improving and a real-time reverse transcription-polymerase chain reaction (rRT-PCR) nasopharyngeal swab was taken. She was advised to isolate with a clinical diagnosis of COVID-19 infection due to the fact that she was a frontline healthcare worker.
On day 4, pyrexia of greater than 38°C and dyspnoea ensued and the patient went to her nearest Accident & Emergency unit (A&E unit). No co-morbidities were noted.
A Chest X-Ray was completed (figure 1A) and she was diagnosed with bronchopneumonia.
The rRT-PCR of her nasopharyngeal swab returned positive for SARS-CoV-2 but the patient’s clinical condition did not meet the institution’s criteria for hospital admission.
TREATMENT
Since the patient did not meet the hospital admission criteria, she was advised to self-isolate at home and follow a prescribed home care protocol as recommended by the clinician. She was instructed and guided on how to monitor her oxygen saturation and respiratory rate, and to return to the A&E unit if she de-saturated or if her condition deteriorated. The patient was advised to start Vitamin C, D and Zinc supplementation.
Home oxygen at two litres per minute was initiated via nasal canulae. The patient was placed in a prone position. Oxygen saturation immediately improved to 93% but the respiratory rate remained persistently high above 20 bpm. Rivaroxaban 10mg twice daily orally was initiated.
INVESTIGATIONS
Complete blood count revealed white blood cells, 9.57 x 109/L (neutrophils, 42.3%; lymphocytes, 50.6%; and monocytes, 6.5%); haemoglobin 13.4 g/dL; mean corpuscular volume, 85.7 fL; and platelets, 344 x 109/L.
Serum laboratory test results were as follows: creatinine, 0.9 mg/dL; sodium, 143 mmol/L; potassium, 4.0 mmol/L; chloride, 108 mmol/L; C-reactive protein, 17.8 mg/L; and quantitative D-Dimer, 0.23ug/Ml.
Spirometer test was conducted and the Flow Volume Test results indicated a mild restrictive abnormality. A reduced FVC with normal FEV1% may only suggest restriction Low vital capacity, which is perhaps due to restriction of lung volumes.
DIFFERENTIAL DIAGNOSIS
Initially the patient presented with non-specific acute symptoms that may be in keeping with a common viral infection (rhinoviruses, non-SARS-CoV-2 coronaviruses and influenza virus). However, with the pyrexia and cough one needs to consider community-acquired pneumonia and SARS-CoV-2.4 The lymphocytosis clearly signified a viral aetiology.
OUTCOME AND FOLLOW UP
On the evening of day 12, the patient felt worse and prednisone 50mg orally per day was initiated by the clinician. Oxygen saturation at this point was 94%, pulse 101 beats/min, respiratory rate 44 breaths/min (bpm) and blood pressure was 82/66 mmHg.
The patient returned to the A&E unit where her respiratory rate was assessed to be 24 bpm. In view of the tachypnoea she was offered an admission bed however declined due to personal reasons.
The patient’s clinical course improved overnight and on day 13, her respiratory rate was 22 bpm. On day 14, her clinical pattern had shown improvement with a respiratory rate consistently below 20 bpm and to the extent that the she was able to walk for the first time in days.