Case Presentation:
A 52-year-old male, with no comorbidities, presented to the emergency department with a 10-day history
of fever and dry cough followed by progressive, exertional shortness of breath. The patient is a non-smoker and worked as a driver. Examination showed a febrile ill-looking patient, in respiratory distress with a respiratory rate of 36 breath per minute and requiring 6L of Oxygen via nasal cannula. Chest auscultation was significant for bilateral crackles, without evidence of raised JVP or lower limb edema. Other examination findings were within normal parameters. The initial investigation was significant for WBC – 17 x10^3/uL, CRP – 131 mg/L, Ferritin – 836 ug/L and bilateral pulmonary infiltrates in Chest X-Ray (Figure 1). COVID-19 rRt-PCR tested positive; hence was diagnosed with sever COVID-19 pneumonia and was started on ceftriaxone, hydroxychloroquine, azithromycin, oseltamivir in addition to as-needed paracetamol. Over the subsequent five days, his oxygen requirements gradually increased, reaching 11 L via a nonrebreather mask. A follow-up chest x-ray showed progression of previously seen bilateral infiltrates (Figure 2).
He was started on methylprednisolone and non-invasive ventilation. Two weeks into admission, the
patient’s condition continued to deteriorate, and intubation was required. Two weeks later, the patient started to spike high-grade fever, with further septic work up revealing pseudomonas aeruginosa and
stenotrophomonas maltophilia in tracheal aspirate culture; hence started on Piperacillin-Tazobactam and
Teicoplanin. CT thorax was done and revealed bilateral diffuse ground-glass infiltrates and airspace
involving almost all lung segments (Figure 3).
Over the next few days, the patient was afebrile, however, repeat tracheal aspirate culture was persistently positive for pseudomonas and stenotrophomonas maltophilia. Five days later, the patient was extubated; but was re-intubated due to respiratory distress and hypoxemia. After multiple failed attempts to wean the patient off mechanical ventilation, he was tracheostomized and eventually de-cannulated. The patient was transferred to the medical ward after staying in the critical care unit for a total of 38 days. The patient was on room air when admitted to the medicine ward. However, a few days later, he started to desaturate gradually. Repeated CXR showed diffuse coarse reticular interstitial changes. COVID-19 rRT-PCR was negative and sepsis workup was unrevealing. A follow-up CT chest was done for further assessment, it showed a slight improvement of the diffuse bilateral ground-glass opacities with re-demonstration of some crazy-paving appearance at both apical segments of upper lobes and it also showed progression of the interstitial fibrotic and bronchiectatic changes predominantly in the anterior aspects of both lungs (Figure 4).The patient was transferred to a long-term care hospital for oxygen supplementation, chest physiotherapy, and physical therapy for his critical care myopathy.