A 51-year-old male patient presented to the emergency department for a two-day history of fever and cough. The patient is known to have ESRD on maintenance hemodialysis three times weekly at our center since late 2012. He is known to have Von Hippel- Lindau (VHL) disease with many of its systemic manifestations including hemangioblastomas of the brain and spine, retinal hemangioblastoma, bilateral renal clear cell carcinoma leading to bilateral nephrectomy and adrenalectomy, and a serous cystadenoma of the pancreas. He also has a history of hypertension on multi drug therapy including an angiotensin receptor blocker, diabetes and coronary heart disease with ischemic cardiomyopathy, he underwent percutaneous coronary intervention to the left anterior descending artery 8 months prior to this admission. His last admission four months prior to this presentation was for ascending cholangitis treated with antibiotics and endoscopic drainage.
At the emergency department, the patient was looking ill, complaining of dry cough, dyspnea and fever. A high-resolution CT of the chest revealed multiple parenchymal consolidations associated with multifocal ground glass opacities. These findings were suggestive of a COVID-19 pneumonia in the setting of the pandemic, and the patient was admitted to our COVID-19 isolated floor unit pending PCR results.
Due to the patient’s symptoms, imaging findings highly suggestive of COVID-19 disease and his rapidly deteriorating clinical status including high grade fever and increased oxygen requirements, he was started upon admission on Azithromycin, Hydroxychloroquine and Piperacillin/tazobactam.
Our center is not equipped with negative pressure dialysis facilities; this implied the patients transfer to the dedicated COVID-19 intensive care unit in order to have his dialysis sessions. Upon his admission to the ICU the patient presented with an APACHE score of 16 and a SOFA score of 13. He developed on day 7 of the illness a rapidly progressive respiratory distress leading to his urgent intubation, and the patient was started on hydrocortisone 50 mg QID and norepinephrine. His clinical status deteriorated with respiratory failure and diffuse patchy infiltrate present on imaging, we decided to treat him with 400 mg of Tocilizumab (HScore of 165) despite the lack of data concerning this molecule in the hemodialysis population.
Two days later the patient presented with a prolonged QT interval (503 ms) requiring the discontinuation of Azithromycine, and Hydroxychloroquine. On day 11 of the illness he was extubated, but intubated again on day 14 secondary to increased bronchial secretions caused by superimposed bacterial pneumonia leading to septic choc with increased dosage of norepinephrine and antibiotic step up to Meropenem.
On day 27 of the illness the patient presented with a fever indicating a second bacterial pneumonia which was later known to be secondary to Stenotrophomonas Maltophilia found in sputum and blood cultures, treated for a total of two weeks with Levofloxacin and Ceftazidime. He was extubated on day 34 of his illness.
Throughout these many complications a total of seven PCRs were performed and remained positive. On day 41 of the illness the patient was treated with ivermectin for a total of three days. Table 1 shows the evolution of the biological parameters.
The last positive PCR was on day 48 of his illness with a negative PCR 52 days after the onset of symptoms, adding up to a total of 52 days of viral shedding. Later, after a second negative PCR the patient was transferred to our floor unit where he was rehabilitated, and discharged on day 69.