A 57-years-old woman presented to the emergency department (ED) - in December 2020 - with complaints of slurred speech, confusion, and left upper limb weakness. Her medical history included suffering from a persistent fever, severe headache, cough, fatigue, anosmia, dysgeusia, sore throat, vomiting, dizziness, fatigue, bony pain, and the reverse transcription-polymerase chain reaction (RT-PCR) assay of nasopharyngeal swab sample was positive for SARS-CoV-2 from one week before presentation in ED. The patient also has diabetes mellites and hypertension in her medical history. All routine diagnostic tests were done, and the patient's blood analysis showed that she had an increase in red blood cells (RBCs), lymphocytes count, a marked increase in C-reactive protein (CRP), and D. Dimer due to infection. She had a slight decrease in mean corpuscular haemoglobin concentration and a marked increase in fasting blood glucose (FBS) as she has diabetes (see Table 1). The patient weight: 70 kg; height: 150 cm; body mass index (BMI): 31 kg /m2; and the blood pressure: 140/100 mmHg sitting. The pulse was 90/min, and oxygen saturation of 90%. Chest computed tomography (CT) and magnetic resonance imaging (MRI) on the brain were done for the patient. CT on the lung showed few right-side apical small ground glass consolidation patches with bilateral mild subpleural lower lobar ground-glass haze more accentuated on the right side that scientifically reefed to right-side viral pneumonia because of COVID-19. Few scattered sub-centimetric emphysematous bullae were noted with fine scattered subpleural atelectatic bands. Mediastinal structures are normal with a patent tracheobronchial tree. There is no mediastinal, hilar adenopathy, or pleural effusion (see Fig. 1). The scanned arterial tree, including the coronary vessels, involved advanced atherosclerotic changes and mild to moderate cardiac chamber enlargement. Visualized cuts of the upper abdomen revealed well defined right adrenal lesion with internal fat density measuring about 5.2 x 4 cm, primarily representing fat-rich adenoma with few bilateral simple cortical renal cysts (see Fig. 1).
Table 1
Laboratory tests and examinations
Laboratory Tests
|
Patient-level
|
Normal Level
|
Unit
|
Complete Blood Count (CBC)
|
Hemoglobin (Hb)
|
13.2
|
12–16
|
g/dl
|
RBCs
|
5.39
|
3.8–4.8
|
X 106/Ul
|
HCT
|
45.1
|
36–46
|
L/L
|
MCV
|
83.7
|
80–101
|
Fl
|
MCH
|
26.5
|
26–32
|
Pg
|
MCHC
|
29.3
|
31–34
|
g/dl
|
Platelet count
|
337
|
150–400
|
X 103/uL
|
WBCs
|
6.5
|
4–11
|
X 103/uL
|
Differential leucocyte count
|
Neutrophils
|
45
|
40–80
|
%
|
1. Staff
|
3
|
0–8
|
%
|
2. Segmented
|
42
|
40–75
|
%
|
Lymphocytes
|
45
|
20–40
|
%
|
Monocytes
|
8
|
2–10
|
%
|
Eosinophils
|
2
|
1–6
|
%
|
Basophils
|
0
|
0–1
|
%
|
INR
|
1.02
|
1–3
|
|
Serum Creatinine
|
0.9
|
0.6–1.10
|
mg/dl
|
S.G.O.T (AST)
|
32
|
Up to 40
|
U/L
|
S.G.P.T (ALT)
|
38
|
Up to 40
|
U/L
|
FBS
|
238
|
99 or lower
|
mg/dL
|
CRP
|
31.7
|
below 3.0
|
mg/L
|
D.Dimer
|
0.720
|
below 0.500
|
ng/mL
|
Ferritin
|
109.9
|
12 to 263
|
ng/mL
|
The patient's blood analysis showed an increase in RBCs, lymphocyte count, a marked increase in CRP, and a slight increase of D. Dimer due to infection. In addition, she had a slight decrease in mean corpuscular hemoglobin concentration and a significant rise in FBS as she has diabetes.
Abbreviations: RBCS: Blood Red Blood Cells (Erythrocytes); HCT: Hematocrit; MCV: Mean Corpuscular Volume; MCH: Mean Corpuscular Hemoglobin; MCHC: Mean Corpuscular Hemoglobin Concentration; MPV: Mean Platelet Volume; WBCS: White Blood Cells; INR: The International Normalized Ratio; SGOT: Serum glutamic oxaloacetic transaminase; AST: Aspartate aminotransferase; SGPT: Serum glutamic pyruvic transaminase; ALT: Alanine aminotransferase; FBS: Fasting blood glucose; CRP: C-reactive protein.
MRI of the brain shown acute infarction of right basal ganglia (see Fig. 2). Intravenous recombinant tissue plasminogen activator (rt-PA) was given to patients within 3 hours after onset. In addition to starting the COVID-19 therapeutic course, the decision was taken to admit the patient to an intensive care unit (ICU) until stabilizing O2 saturation. We treated the patient with intravenous ceftriaxone (2 g/day for 14 days), methylprednisolone (60 mg daily over six months), and anticoagulation over three months. Symptoms resolved entirely within 72 h. The patient was discharged after two weeks of antibiotic therapy. During a follow-up period of two weeks, no new symptoms occurred, and the second nasopharyngeal swab by RT-PCR assay was negative for SARS-CoV-2.