COVID-19 Case: 62-year-old Man with Severe Cough and Shortness of Breath

00:01 However, he comes back to us two days later with persistence of his initial presenting complaints, but his cough is now worse - still not productive but he's finding it difficult to breath both with tightness of his chest and also shortness of breath associated with the coughing.

00:17 He now has even more pronounced anorexia, he’s lost his appetite completely.

00:22 Still no other GI symptoms and still no new complaints other than as noted above.

00:27 His examination continues to demonstrate a highly febrile adult male who is still tachycardic, even more tachypneic.

00:35 And now without even changing his medications, his blood pressure, if anything, is low.

00:41 So, we now have a patient who has become hypotensive which is definitely a cause of concern.

00:46 This time, we remember to do our spot check for his peripheral oxygenation and indeed he has an oxygenation of only 89% on room air.

00:56 This is cause for concern regardless of the viral etiology but certainly if we're considering COVID-19.

01:02 This would be a trigger for us to do a further evaluation and further intervention.

01:07 His chest exam now demonstrates diffuse fine crackles bilaterally.

01:11 His air entry is adequate but not great and he does show increased work of breathing.

01:16 The rest of this exam however is unchanged.

01:18 So again, what should leap out at us is the worsening of symptoms especially the cough, the development of shortness of breath and an associated decreased peripheral oxygenation of less than 90%.

01:30 These are two red flags for COVID-19 suspect patients that would significantly suggest a need to do further intervention and further evaluation.

01:40 Similarly, he now has evidence of hypotension which could be a complication of advancing COVID-19 or of a potentially superinfection from a viral etiology with bacterial sepsis.

01:53 So long story short, Mr. Lecturio has got our concern or interest and we need to consider what to do next.

02:00 So, what are next steps in the assessment? If we haven't already, we'll certainly wish to evaluate for other viral etiologies and consider now testing for COVID-19, given again the fairly nonspecific nature of presentation for all of these, Mr. Lecturio could still have any one of the etiologies you see listed on the screeni n front of you - any of the influenzas, parainfluenza, rhinovirus, coronavirus, COVID-19 disease, anything else.

02:31 What are the next steps? Do we now consider testing? what we do next? And in fact, we may wish to consider doing blood testing along with testing specifically for COVID-19 and also considering imaging.

02:44 What are we gonna see with these in the setting of COVID-19? CBC - we're looking especially for either a normal or potentially reduced peripheral white blood cell count.

02:54 So leukopenia, along with a lymphopenia - reduced percentage of lymphocytes and maybe even in some cases, about 40% so far, thrombocytopenia - decreased platelet count.

03:06 The inflammatory markers, we're looking to see an elevated C-reactive protein or creatine kinase and elevated lactate dehydrogenase.

03:14 Something suggest that there is cytokine storm and/or inflammatory burst occurring as these are highly associated with advancing disease in COVID-19.

03:25 Organ function - we absolutely want to see where is kidneys are at, where his liver is at, where his heart is at.

03:30 So doing a comprehensive metabolic panel to include signs or indicators of kidney function, liver function, liver numbers and then sending cardiac enzymes.

03:42 All of which are indicated.

03:44 Doing a blood gas - if we want to confirm our lower peripheral oxygenation and see is he indeed failing to exchange oxygen and carbon dioxide? What is his pH? Do we have respiratory acidosis? alkalosis? etcetera.

03:58 Sending a blood culture, well yes because even if this is COVID-19 or other viral etiologies, there's still could be the potential of a secondary bacterial infection.

04:08 Yes, we want to consider COVID-19 testing because we now wish to do further emergent care.

04:14 Mr. Lecturio requires help and we need to know if he is a suspect patient.

04:19 Then imaging, considering chest radiograph versus computed tomograpy or CT scan.

04:24 Of the two, the CT scan will be more specific and sensitive for findings that we wish to demonstrate in the setting of COVID-19.

04:33 Chest radiograph, however is easier to obtain, easier to perform and thus may be the first step while we're contacting the radiology suite to get our next set of testing.

04:43 So, in this case, with the anticipated results as we just discussed, Mr. Lecturio's results start to come back.

04:50 And indeed, his complete blood count shows a low white blood cell count of 2.7 or 2700 cells per mm3, with 67% neutrophils, 25% lymphocyte and 5% monocytes.

05:03 So indeed, he now is leukopenic and definitely lymphopenic.

05:07 His hemoglobin/hematocrit are normal but he is thrombocytopenic at 85000 (per mm3).

05:12 His inflammatory markers demonstrate slight elevation of the C-reactive protein with 4.7 (mg/L), normal being less than 3 (mg/L) and his lactate dehydrogenase is also slightly elevated at 360 (U/L).

05:24 Moving on then to his organ function.

05:27 Indeed he shows evidence of some early renal insufficiency with a slightly elevated blood urea nitrogen at 24 (mg/L) and an elevated creatinine of 1.4 mg/dL In addition, his transaminases AST and ALT are 85 (U/L) and 79 (U/L) respectively, although his total bilirubin is normal and his troponin I is slightly elevated at 0.5 ng/mL.

05:54 So he has evidence of a mild multiorgan disease which will go along with potentially invasive bacterial sepsis, a SIRS - a systemic inflammatory response syndrome but also with multiorgan dysfunction syndrome which can be seen with more advanced or severe COVID-19 disease.

06:12 His blood gas obtained from an arterial source shows a slightly elevated pH of 7.47, a low partial pressure O2 of 55 mmHg, partial pressure of CO2 of 32 mmHg, and his bicarb (HCO3) is in the normal range of 25 mmol/L.

06:28 By then and again, his peripheral oxygenation is low now at 87% Blood culture.

06:34 He has a blood culture is sent in this case to look for a bacterial superinfection or pathogens and is negative at 48 hours which suggests - it doesn't exclude - but it does suggest that there is no bacterial superinfection at this stage.

06:49 Chest radiograph indeed was performed, just because it was easier and faster to obtain and it showed the typical nonspecific bilateral infrahilar airspace opacities.

06:59 which could be seen in any viral process or even in nonspecific atelectatic changes.

07:04 However, there's no evidence of increased fluid because the costovertebral angles are clear.

07:10 A chest CT scan though does demonstrates bilateral nodules and the expected peripheral ground glass opacities throughout the lung fields as well as some mild interlobular septal thickening.

07:22 All these can be seen in COVID-19 disease, and also to a significant extent in acute respiratory distress syndrome (ARDS) caused by a variety of pathogens.

07:34 So where are we at then? What are the ultimate diagnoses? In Mr. Lecturio's case, rapid testing for influenza came back negative as did molecular diagnostics for other respiratory virus panels.

07:47 This does not completely exclude those diseases but it makes them less likely.

07:52 However his nucleic amplification assay is positive for the SARS-coronavirus-2, the cause of COVID-19.

07:59 So we can make a strong presumptive diagnosis of COVID-19 Knowing however, that coinfection is still possible especially with influenza and also potentially bacterial superinfection.

08:12 So this case presentation shows a typical progression and typical findings for an advanced case of COVID-19.

08:20 However which began with mild disease and you can see, I hope you can see that it's very difficult to differentiate COVID-19 caused by SARS-coronavirus-2 from other viral pathogens causing upper and lower respiratory tract infections.

08:37 However, hopefully this case is instructive in looking at how a patient may progress and ultimately come to medical attention and deserve further evaluation.

08:46 Now, looking specifically again what I shared with you with Mr. Lecturio, What is his risk of critical disease? Looking at his age, age 62, well so an age of 65 has been looked at as a strong cutoff, above which a risk of critical disease is quite significant.

09:04 However the risk begins to escalate even in the late 20s.

09:09 So age 62 would be a moderate risk factor for risk of critical disease.

09:14 However, in specific to this case, Mr. Lecturio does have two comorbidities, that being hypertension and diabetes mellitus, both of which increases risk for severe disease, Further when he represented to us the second time, the peripheral oxygenation was less than 93% He also had elevations of his transaminases and worsening of his renal function.

09:39 So he has multiorgan dysfunction, some hypotension, definitely a difficulty in air exchange in oxygenation and an impending hypoxic respiratory failure.

09:50 So, Mr. Lecturio's risk of critical disease is actually quite extensive and this case would suggest one who definitely deserves hospitalization, close monitoring, and further support as necessary.

10:01 So to wrap things up, starting from a mild, nonspecific illness, yet with risk factors which we've identified and also with comorbidities, this case shows a very unfortunate but typical progression into much more severe critical disease, along the way being differentiated from other viral pathogens which may contribute to or cause instead of the disease which we're looking at as caused by COVID-19.