Case History
A 47-year-old man presented with a 4-day history of fever and dyspnea. Two days before hospitalization, he tested positive for severe acute respiratory syndrome coronavirus 2, assessed via reverse transcription polymerase chain reaction test. He also had a 5-year history of untreated type 2 diabetes mellitus. On admission, his hemoglobin A1c level was 13%. He reported having no prior contact with other COVID-19 patients.
The patient presented to the hospital with a body temperature of 38.3°C, heart rate of 90 beats/min, blood pressure of 132/83 mm Hg, respiratory rate of 24 breaths/min, and peripheral capillary oxygen saturation of 93% on ambient air. Chest computed tomography revealed ground-glass opacities and bilateral patchy shadows consistent with those of COVID-19 pneumonia. On the second day of hospitalization, the patient’s respiratory condition worsened; hence, he was transferred to the intensive care unit (ICU) where oral intubation was initiated to provide artificial respiration. The patient had remittent fever, with a temperature ranging from 37.5°C to 40.4°C, on hospitalization days 6–8. On day 9, he developed sustained fever, with a temperature of 40°C to 41℃ (Figure 1), for which acetaminophen was ineffective. This was accompanied by a marked disturbance in consciousness. His systolic blood pressure dropped below 70 mm Hg, leading to warm shock. Respiratory condition further deteriorated on the night of day 9, with the partial pressure of arterial oxygen/fraction of inspired oxygen ratio decreasing from 202 mm Hg to 140 mm Hg. Large-volume infusion of fluids was started along with the administration of vasopressors (noradrenaline, vasopressin, and adrenaline) and hydrocortisone. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated on the night of day 9 itself owing to worsening hemodynamics. Laboratory results (Table 1) revealed lactic acidosis, acute kidney injury, disseminated intravascular coagulation, hepatic dysfunction, and significant rhabdomyolysis. After the initiation of VA-ECMO, the patient’s sustained fever was rapidly alleviated, and the symptoms of multiorgan failure also began to improve gradually. VA-ECMO support was withdrawn on day 22. Life-prolonging treatment was withheld because of repeated severe cerebral infarction and hemorrhage that led to central nervous system damage. The patient died on day 30. Although favipiravir was administered to treat the patient’s infection from the day 1 of his admission to the ICU, it was discontinued on day 7 because of the possibility of drug-induced rhabdomyolysis. Broad-spectrum antibiotics were administered from the day he was admitted to the ICU to prevent secondary bacterial infections. Sputum culture did not show the growth of any pathogenic organism.