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 VA-ECMO support was withdrawn on day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.