Case Presentation
A 65-year-old male with accelerated phase chronic myelogenous leukemia (AP-CML) presented to the emergency department with a 3-day history of febrile sensation (not measured by the patient) and progressive shortness of breath, mainly with exertion. Also, he had had a productive cough with a small amount of yellowish sputum and intermittent pleuritic chest pain for a few days. He denied any history of runny nose, sore throat, loss of smell or taste sense, night sweating, or weight loss. There was no history of contact with sick patients, especially with COVID-19, nor recent travel.
He had had AP-CML for 4 years, currently in major molecular remission, and the latest BCR-ABL level was 0.04%; he was on dasatinib 140 mg but decreased to 100 mg because he had pancytopenia, which was resolved after adjusting the dose. Also, he had a chronic right-sided small loculated pleural effusion which was attributed to dasatinib (Fig. 1).
On arrival to the emergency department, he was febrile, and his recorded temperature was 38.4°C. He had an oxygen saturation (SpO2) of 94% on 6 L via a nonrebreather mask, a respiratory rate of 19 breath per minute, a heart rate of 104 beats per minute, and a blood pressure of 138/79 mm Hg. He was conscious, oriented, and feeling well. Breath sounds were decreased on the bilateral lower lung fields with a coarse crepitation in the right middle to lower zones. The examination of other systems was unremarkable.
Laboratory findings (on the admission day) showed pancytopenia, increased PTT, INR and elevated D-dimer. The liver and kidney functions were normal. C-reactive protein level was elevated and LDH level was normal (Table 1).
The chest X-ray showed bilateral lower lobe collapse and consolidation with pleural effusion, more noted on the left side, which is increased compared to baseline (Fig. 2). Considering the patient's background, clinical presentation and the current pandemic, we tested him for COVID-19 and it came back positive.
Chest computed tomography (CT) showed bilateral pleural effusions evident on the left side with lower lobe subsegmental collapse and consolidation as a consequence as well as likely right anterior empyema formation and bilateral lower lung lobe post-inflammatory changes (Fig. 3, 4). There was no growth in blood nor sputum cultures. Also, acid fast bacilli smears and PCR were negative.
The patient was admitted with neutropenic fever and COVID-19 and was initially started on hydroxychloroquine 400 mg orally daily, azithromycin 500 mg p.o. daily, oseltamivir 150 mg p.o. b.i.d., based on local COVID-19 management protocol, and piperacillin/tazobactam 4,500 mg i.v. every 8 h. Dasatinib was kept on hold as recommended by the hematology team.
Diagnostic thoracocentesis was done to rule out other underlying causes, 500 mL was removed, and a drain was inserted. Pleural fluid analysis showed exudative lymphocytic pleural effusion and negative acid fast bacilli smears, PCR and cultures.
On day 4, he started to improve, and he was off oxygen; his SpO2 was 95% on room air. However, he became more neutropenic (Table 2).
On day 8, he had dyspnea after coming back from the bathroom, and became tachypneic (respiratory rate: 43 breaths per minute) and tachycardic (heart rate: 115 beats per minute), requiring 10 L of oxygen via the nonrebreather mask to maintain his SpO2 level above 94%. Chest auscultation showed diffuse bilateral crackles, and there were no signs of fluid overload. Arterial blood gas results were pH 7.48 (normal range: 7.35–7.45), pO2 63 mm Hg (normal range: 83–108), HCO3 27.4 mmol/L (normal range: 23–27) and pCO2 34 mm Hg (normal range: 35–45). The patient was given oxygen and salbutamol nebulization but without significant improvement. The repeated chest X-ray (Fig. 5) showed bilateral infiltrations and his calculated PaO2/FiO2 ratio = 143 (PaO2: 63 on 6 L oxygen, FiO2 44%). Cardiac causes have been ruled out, so he fulfilled the ARDS criteria. Moreover, he was still neutropenic, and his ferritin, LDH and triglyceride levels were elevated (Table 3). So, the patient was transferred to the intensive care unit.
The infectious disease team recommended to manage him as a case of severe COVID-19 pneumonia complicated by ARDS, which might be due to a cytokine storm. Therefore, they added ritonavir plus lopinavir 500 mg orally daily for 14 days, tocilizumab 400 mg i.v. single dose, and methylprednisolone 40 mg i.v. every 12 h for 5 days, and BiPAP has been applied to improve his SpO2 level. After a few hours, he started to improve with this regimen, so he was shifted back to a simple face mask, and gradually the amount of oxygen has decreased. The repeated ABG showed an improvement in pO2 (100 mm Hg).
On day 12, the chest X-ray was repeated and showed satisfactory lung field expansion with no significant interval change regarding the bilateral airspace opacities. Right-sided pleural effusion is still noted with progression in the segmental right lower lung zone collapse (Fig. 6).
After completion of the treatment, he has gradually improved, and his SpO2 is 98% on ambient air. However, his ANC is fluctuating between 0.4 and 1.8 × 103/μL and he was on daily filgrastim (Fig. 7), so dasatinib has not been started yet. He is still in the hospital but off medications and waiting for his repeated PCR to be negative for discharge. The latest one was done on day 30 (Table 4).