Case report
The patient is a 63-year-old male kidney and liver transplant recipient who presented to the Emergency Department (ED) after developing symptoms of mild fever, shortness of breath, and cough. His vitals and physical exam in the Emergency Department were within normal limits, except for a temperature of 38 degrees Celsius. His initial chest x-ray on the day of admission (Day 1) was unremarkable. He tested negative for influenza and COVID-19 via polymerase chain reaction (PCR) and was admitted to the hospital. At the time of admission, he had a normal white blood cell count (6.94 × 109/liter), decreased absolute lymphocyte count (2.9 %), and normal liver function tests. Cytomegalovirus and Bordetella PCR serology were also negative. His home immunosuppressant regimen consisted of mycophenolic acid 500 milligrams daily, prednisone 5 milligrams daily, tacrolimus 2 milligrams twice a day.
On day 2 of the admission, the patient was switched from oral prednisone to methylprednisolone 40 milligrams administered every eight hours intravenously. On day 3, he received cefepime 1 g over six hours. He also received five doses of hydroxychloroquine 400 milligrams on days 3–7.
On day 4, the fever subsided and vitals remained within normal limits. However, he developed increasing shortness of breath with new diffuse expiratory wheezes on physical exam. Repeat chest x-ray showed right lower lobe infiltrates and CT Thorax without contrast showed right upper, middle, and lower lobe infiltrates with ground glass appearance consistent with a viral pneumonitis. This later progressed to bilateral ground glass opacities as pictured in Fig. 1, Fig. 2, Fig. 3 and warranted transfer to the Intensive Care Unit (ICU). Test for COVID-19 serum antibodies performed at this time was positive for COVID-19 IgG antibodies. On Day 4, he received one dose of tocilizumab 4 mL/kilogram. Within 24 h of receiving this medication, his shortness of breath started to improve. His oxygen requirement dropped to 2–3 liters via nasal cannula with exercise while maintaining an oxygen saturation of 86–94 % over the next two days. His chest x-ray also showed improvement, as shown in Fig. 4 . Overall, he began to show clinical signs of improvement. Mycophenolic acid and tacrolimus were discontinued on day 5. Table 1 shows the lab results for the patient through the first seven days of his hospital stay.
Fig. 1 CT Thorax without contrast: bilateral ground glass opacities.
Fig. 2 CT Thorax without contrast: bilateral ground glass opacities.
Fig. 3 CT Thorax without contrast: bilateral ground glass opacities.
Fig. 4 Chest x-ray improved after six days of treatment.
Table 1 Patient labs from Day 1–10.
Labratory Test Results 4/11/20Day 1 4/13/20day 3 4/14/20day 4 4/15/20day 5 4/16/20day 6 4/17/20day 7 4/18/20day 8 4/20/20day 10
WBC(4.5–11 × 109/L) 6.94 6.73 12.13 8.27 8.03 8.89
Lymphocytes(30–45 %) 2.90 % 3.70 % 3.30 % 6.50 %
Creatinine(Male: 0.70−1.30 mg/dL) 1.20 1.30 1.50 1.10 1.00 0.90 0.90
AST(10−40 units/L) 21 25 29 34 37 25 22
ALT(10−40 units/L) 29 26 28 45 64 53 51
Alkaline phosphatase(30−120 units/L) 81 75 72 68 63 63 72
LDH(80–225 units/L) 226.00 344.00
C-reactive protein (<0.8 mg/dL) 3.70 1.20 0.60
IL-6(5−15 pg/mL) 18.2 670.8 392.8 280.7
Prograf/ Tacrolimus levels(5.0−15.0 ng/mL) 17.30 14.80 7.90
Ferritin(male: 54–755 pmol/L) 336.50 225.90
VBG pH 7.47pO2 81pCO2 32HCO3 23.20
ABG pH 7.42pO2 72pCO2 33HCO3 21.4
Serology
Influenza Negative
Coronavirus Negative Positive
However, on Day 7, he decompensated requiring intubation and mechanical ventilation. The critical care team also placed him on a rotator bed. On day 8, his oxygen requirements substantially increased requiring an increase of oxygen to 1 L. At this time, he received a second dose of tocilizumab.
The patient remained critically ill following intubation. Seven days after intubation he developed a right sided pneumothorax and required a chest tube. The liver function tests, blood urea nitrogen (BUN), and creatinine remained stable. During his ICU stay, he was fully therapeutically heparinized as well. He developed no evidence of secondary bacterial infection. We obtained consent and administered 200 mL of convalescent plasma. He remained stable without significant change in his condition over the next several days.
On Day 14, the pneumothorax resolved and he began weaning off the ventilator.