Case history:
A 40 year old underprivileged conjoined twin (Mr. A and Mr. B)
(Pygopagus) presented to local hospital (200 km distant from our
center, which is a tertiary health care facility) with high grade fever
(102 degrees), worsening dyspnea, cough and severe fatigue for past
three days. The patient’s primary treatment was delayed due to
transportation difficulties during the lockdown, as well as shame and
reluctance on the part of family members to accompany them. The patients
were managed by telemedicine video call from our center. As they
presented primarily with respiratory symptoms at the time of second wave
of COVID-19 pandemic, a presumptive diagnosis of COVID-19 infection was
made. Nasopharyngeal swabs of both the patients were sent for testing of
SARS CoV-2 virus. Both of them had positive reports with CT (Cycle
threshold) value of 13 and 12 respectively. The conjoined twins (Patient
A) were already taking treatment from neurosurgery outpatient department
of our center for dorsal spine tuberculosis with paraparesis for past 1
year. Mr. A was on antitubercular medications for past 1 year. He was
provided with custom fitted kyphotic brace made from a cast on his
cervico – dorsal spine. They were kept on a regular follow-up through
telemedicine due to ongoing Covid-19 pandemic and they were embarrassed
to travel large distances for medical appointments. They also used to
avoid crowded places since everyone would look at them as if they were
aliens. Therefore, video consultations were provided and routine liver
function test were shared on our whatsapp group. They did not have any
other significant medical histories. However, they had a very poor
hygiene due to their low socioeconomic status (Figure 1.
A-C) .
After discussion with the treating team at local hospital, it was
advised to shift them to our tertiary health center. On arrival, patient
was immediately shifted to ICU on two combined beds. They were connected
to high flow nasal cannula (60 litres/min), and were maintaining an
oxygen saturation of 80- 84 % which was not adequate. Arterial blood
gas analysis was done and it was observed that PaO2/FiO2 ratio of both
patients (Mr. A and Mr. B) were between 70-80. They had metabolic
acidosis with high lactate and low bicarbonate (Table
1). As they were not maintaining adequate oxygen saturation, had very
high respiratory rate along with worsening of ventilatory parameters,
they were intubated and taken to mechanical ventilation. Intubation was
done for each of them in lateral position. Two separate mechanical
ventilators (Hamilton-medical) were kept and VCV (volume controlled
ventilation) mode with FiO2 80 to 90 % and PEEP 6 to target a
saturation of 94% was initiated. Deep sedation
targeting Richmond Agitation Sedation Scale of -4 was initiated using
titrated doses of fentanyl at the rate of 25 to 150 mic/hour and
midazolam infusion at the rate of 1-3 mg/hour. But as persistent
asynchrony was present with desaturation, muscle relaxant infusion with
vecuronium 2 mg/hr was initiated. The airway tubing and intravenous
lines of each patient were color coded to avoid confusion and drug
errors. We could not place central neck line in them as it was quite
difficult to insert due to their position. Instead, peripherally
inserted central line (PICC) was placed. To confirm absence of cross
circulation between them via the sacral venous plexus, atropine was
given to patient A, he developed tachycardia but patient B had normal
pulse rate ensuring absence of any cross
circulation4.After confirmation of absence of any
cross-circulation, anti-covid medications were started as per their
individual estimated body weight.
Bedside Chest X ray was done which showed multiple infiltrates, linear
and ground glass opacities in both the lungs with consolidation in right
lung of patient A. Patient B had consolidation in bilateral lung fields,
suggestive of severe ARDS (Figure 2 A and B). His
biochemical parameters were suggestive of cytokine storm. There was
significant leukocytosis with neutrophillia. His renal function and
serum electrolytes were normal. CRP and ferritin was highly elevated
suggestive of inflammatory cycle. Procalcitonin and D-dimer were
markedly raised suggesting ongoing septicemia and thrombosis. However,
liver function and lipid profile were normal. Lactate dehydrogenase
(LDH) and Interleukin-6 (IL-6) were significantly raised in both the
patients suggestive of severe covid-19 infection. Cardiac profile,
myocardial Creatinine phospho kinase (CPK-MB) and Troponin-I were
normal. Electrocardiogram showed normal sinus rhythm. Echocardiogram
didn’t show any valvular malfunction or defect.
Inj. methyl prednisolone (pulse dose) 500 mg once in a day were given to
both of them separately for three consecutive days. Low molecular weight
heparin was also started to both the patients at a dose of 60 mg twice a
day along with intravenous injections of piperacillin and tazobactum
(4.5 gm) thrice a day. Injection toclizumab was also given to both of
them. For next three days, both of them were kept on maximum ventilator
support (FiO2 – 100%, PCV mode, Pi-30, PEEP – 18 cmH2O). We changed
the mode to pressure control mode to prevent any barotrauma arising out
of increasing airway pressures. Over the period, the compliance
gradually decreased with increasing plateau pressure (around 40-50)
(Figure 3A). However, despite providing ventilatory
support their oxygen saturation was not adequate (SPO2- 85 %). However
due to conjoint sacroiliac junction, they would always maintain
obliquity in their posture (lateral position). It was nearly impossible
to provide them ventilation in prone position in spite of being in
moderate to severe ARDS. Gradually their saturation level dropped down
from 85% to 30-40% in next three days (Figure 3B) with
100 % FiO2 and PCV Mode, Pi 38 and 18 PEEP and unfortunately they
suffered cardiac arrest. Patient B expired on day 3 of admission and
patient A expired on day 4 of admission after 14 hours of gap. The
hemodynamic parameters were stable until the last day of treatment
before patient A expired.