A 63-year-old single man came to our institute (Bushehr medical university hospital, Bushehr, Iran, a designated COVID-19 referral center), with the manifestations of fever and shortness of breath on March 22, 2020. The patient had a history of smoking and addiction, but no history of respiratory or cardiovascular diseases, or chemotherapy and transplantation. Upon arrival, the patient was febrile (38.9 oC). His heart rate (HR) was 100, with high blood pressure (BP) (160/80 mmHg). Besides, his oxygen saturation was 89% in room air.
Laboratory investigations of the blood parameters showed that the complete blood count (CBC) was normal, except for hemoglobin (Hbg) levels. His white blood cell (WBC) count was 8.5 × 109/L (normal range: 4–11 × 109/L), the lymphocyte count was 1.24 × 109/L (normal range: 1–4.8 × 109/L), blood platelet (Plt) count was 286 × 109/L (normal range: 140–400 × 109/L), and hemoglobin levels were 6.8 g/dL (normal range: 11.5–15.5 g/dL). Other lab measurements were within normal ranges, including renal and liver function tests.
According to the patient's history, the interval between the first symptoms and severe shortness of breath was one week. A high-resolution computed tomography (HRCT) scan of the chest was performed (Fig. 1) several days after the onset of shortness of breath, which led to a high suspicion of SARS-CoV-2 infection, due to the presence of the bilateral multifocal ground-glass opacity (GGO) pattern. Subsequently, the COVID-19 infection diagnosis was confirmed by an upper respiratory tract swab (nasopharyngeal and oropharyngeal) for molecular evaluation, using the real-time reverse polymerase-transcriptase chain reaction (rRT-PCR method).
As soon the patient was admitted to the ward, he received a hydroxychloroquine 400 mg stat and 200 mg bid, azithromycin 250 mg daily, and ceftriaxone 1gr bid. The fever continued until the 3rd. day of admission. Ceftriaxone was discontinued and meropenem and vancomycin were substituted on the 4rd. day of admission. Also, for control of fever intravenous acetaminophen (Apotel) was used. The patient’s oxygen saturation was 89% in room air, after receiving supplemental oxygen by mask it improved but after its removal, it declined again. Dyspnea and shortness of breath continued. We decided to transfused packed RBC (PRBC) to increase hemoglobin, in accordance to improve oxygen saturation. After transfusion of the first unit of PRBCs, the patient's hemoglobin levels and oxygen saturation were evaluated. Blood hemoglobin levels and oxygen saturation after transfusion of the first PRBC unit increased to 8.7 g/dL and 91% in the room air, respectively. Improving of general condition, dyspnea, shortness of breath, and oxygen saturation, after the first PRBC unit, we decided to transfuse the second PRBC unit. These values were raised to 9.9 g/dL and 96%, respectively, after the transfusion of the second PRBC unit. After receiving two PRBC units, the patient's general condition improved greatly and dyspnea disappeared. At this stage, a CT scan was taken again from the patient, which indicated an improvement in the condition of the lung (Fig. 2).
The patient was discharged from the hospital on March 29, 2020, one week after the initial visit to the hospital, in good general condition, without fever and shortness of breath. In outpatient follow up two weeks after hospital discharge his general condition was good, there was no fever, dyspnea and shortness of breath, and oxygen saturation in room air was 97%.