COVID-19: Clinical worsening and radiographic progression in a polymorbid patient with SARS-Cov-2-associated pneumonia
date : 05.05.2020
*Tsvetomir Karagechev
*Galin Petkov
**Anton Penev
*Galina Kirova-Nedyalkova
*Department of Radiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria **Department of Pulmonology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
dr.karagechev@outlook.com
Keywords: COVID-19, Radiography, viral pneumonia, comorbidity
Clinical history: We present a 72-year-old female dialysis patient with multiple comorbidities and a positive RT-PCR test for COVID-19 after close contact with an infected person. At admission the patient presented with mild symptoms but subsequently her clinical condition deteriorated rapidly with worsened laboratory results and radiographic progression.
Imaging findings:
Baseline CXR showed rib deformities, bilateral calcified pleural plaques, symmetrical perihilar opacities representing chronic non-cardiogenic pulmonary edema with sparing of peripheral lung fields (Figure1).On the third day of admission, the patient began complaining of severe dyspnea, cyanosis and fever; CRP-115,64 mg/L, O2Sat-83% and lymphocytopenia-11,9%. AP CXR showed increased bilateral perihilar shadowing and affection of the peripheral lung fields (Figure2). After incomplete dialysis treatment in the next three days, AP CXR showed confluent perihilar consolidations with air bronchograms bilaterally. The imaging findings corresponded with the patient’s deteriorated respiratory status: hypercapnia, O2Sat-78%, elevated CRP-208,04mg/L and lymphocytopenia-3,7% (Figure3). After successful dialysis, AP CXR showed regression of the perihilar consolidations with increased peripheral opacities and a new infiltrative opacity in the right upper lung field. Within the context of the detection of staphylococci in blood culture, the imaging findings were in keeping with superimposed bacterial infection.
Final diagnosis: Viral pneumonia, caused by SARS-CoV-2 - COVID-19
Discussion:
As the COVID-19 pandemic develops, numerous studies have described the radiographic and CT imaging features of the disease. ESR, ESTI, and the Fleischner Society have all published guidelines for standardized reporting of related imaging findings and have defined criteria for moderate or high level of suspicion for pulmonary involvement in the context of COVID-19. The progression of the disease towards acute respiratory distress syndrome is well described. In this case, the radiographic sign of a ,,white lung’’ is observed – a nonspecific pattern that is associated with diffuse alveolar damage (DAD). We present a case of a comorbid patient with underlying non-cardiogenic pulmonary congestion and infection with SARS-CoV-2, which was followed by rapid clinical deterioration and ultimately tracheal intubation. During the course of the disease, a secondary bacterial infection altered the imaging findings. In patients with progressive worsening of the respiratory status, follow-up chest radiographs are recommended in order to appreciate new evidence of consolidation, pulmonary abscess or pleural effusion, resulting from secondary bacterial infection, which would influence the therapeutic approach. The presented case demonstrates the typical aggravation of COVID-19-associated pneumonia and the dynamics of the radiological progression, along with the deterioration of the patient’s clinical condition and laboratory parameters. The clinical chronology is shown in Figure 5.
Differential diagnosis:
Viral pneumonia with different etiology, Multifocal bacterial pneumonia, Noncardiogenic pulmonary edema, Hypersensitivity pneumonitis.
Take home messages:
In conclusion, the presented case from our clinical practice monitors the clinical symptoms and the laboratory parameters in a comorbid patient with SARS-CoV-2-associated pneumonia. Corresponding dynamics in the radiographic progression is observed. At admission, there are subtle imaging findings that represent moderate radiological suspicion of COVID-19 whereas later there is radiographic evidence of severe bilateral infiltration of the lung parenchyma. As in other infectious diseases of viral etiology, patients with multiple comorbidities are at higher risk for poorer clinical outcome and in this case the course of the disease is unpredictable. In the setting of COVID-19 pandemic, it is highly recommended that the medical staff is aware when comorbid patients are presenting with epidemiological risk factors, despite the initial lack of clinical symptoms.
Bibliography:
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