In this issue, we will discuss case reports of COVID-19 infection.
As for COVID-19, there have been a number of reports about the experiences of people who have been infected, and in general terms, one person's experience is enough information.However, even if medical personnel have these stories, they cannot apply them to all clinical cases, and they do not know the specific outcomes, so they learn from case reports.This time, two case reports were reviewed, and I would like to introduce them including the details.
Case 1
68 years old
Heavy smoking history (for 60 years)
Hypercholesterolemia
After 3 days of fever and myalgia, the patient showed multiple pneumonias (22 cycles/minute) and low oxygen saturation of 88% in room air, and physical examination showed coarse crackles in both lower lung fields.
RT-PCR test was positive for SARS-Cov-2.
CT scan on initial admission shows peripheral frosted opacity with underlying lobar central emphysematous lesions with enlarged COVID-19 lesions estimated to be 10-25% of the lung parenchyma.ECG is normal.Moderate lymphopenia is present, with increased levels of CRP and D-dimer.BNP and troponin I levels were normal.LA test was negative.Arterial blood gases in the nasal cannula (8L/min) showed PaO2 60 mmHg, PCO2 37 mmHg, and SaO2 90%.Based on these test results, treatment with LMWH, enoxaparin 40 mg once daily, ceftriaxone, and hydroxychloroquine was initiated.
The next day, the oxygen flow rate increased to 15 L / min, the patient did not need to be put on a ventilator, and after 8 days, her symptoms had improved and she was discharged.Forty-eight hours after discharge, the patient rapidly showed dyspnea and severe hypoxemia.Her D-dimer level was elevated, but her troponin I and BNP remained normal.
A repeat chest CT scan was performed and showed an infected lesion with 30% dilatation and pulmonary embolism diagnosed, as well as abnormalities in the right pulmonary artery and right upper lobe.Treatment was started with heparin and switched to LMWH twice a day after 48 hours.The second LA test was positive.Vitamin K antagonist therapy with warfarin was started, and a second LA test was planned for 3 months later to determine if anticoagulation should be discontinued.It was recommended that the patient consult a cardiologist one month after discharge.
This was the case.
Case 2
Age 62
Dilated cardiomyopathy
Cardiovascular risk factors (smoking, hypertension, type 2 diabetes, hypercholesterolemia)
The patient came to the hospital because of dyspnea after 5 days of fever, cough, and myalgia.
Examination was done on admission, but showed no abnormalities.Lung auscultation did not detect any abnormal sounds.RT-PCR test was positive for SARS-Cov-2.CT scan was normal.ECG showed sinus tachycardia.CRP was slightly increased, but not leukocytosis.No troponin, BNP, or D-dimer tests were performed during the hospitalization.Despite abnormal arterial blood gases in the room air on admission, the patient received low-flow nasal oxygen for two days.A once-daily enoxaparin 40 mg dose was the only treatment given during the five-day hospitalization.Four days after discharge from the hospital, the patient was seen again for dyspnea.A second CT scan showed multiple subpleural frosted opacities and abnormal findings diagnostic of pulmonary embolism in the left lower lobe.A CT angiographic four-lumen view of the heart showed normal right ventricular size and no elevated cardiac biomarkers.Echocardiography demonstrated normal right ventricular size and pressure with a left ventricular ejection fraction of approximately 40%.Inflammatory markers were increased.The D-dimer level measured 48 hours after the start of LMWH therapy was normal.No lupus anticoagulant factor was detected and the patient was switched to apixaban medication.The duration of medication was 3 months, and the patient was advised to consult a cardiologist one month after discharge.
Mohamad Kanso, Thomas Cardi, Halim Marzak, Alexandre Schatz, Loïc Faucher, Lélia Grunebaum, Olivier Morel, Laurence Jesel, Delayed pulmonary embolism after COVID-19 pneumonia: a case report, European Heart Journal - Case Reports, Volume 4, Issue 6, December 2020, Pages 1-4,
Conclusion
These were two cases of pulmonary embolism after discharge from the hospital, even with properly performed procedures.About two weeks after discharge from the hospital, the clinical symptoms that had improved before discharge recurred, and imaging studies that had shown no abnormalities were altered.In order to reduce the number of infected people and to lift the declaration of a state of emergency, there seems to be an excessive obsession with "numbers," such as the number of available clinical beds.In fact, there have been cases of sudden changes after discharge from the hospital, so when you realize that you cannot be too careful after discharge, you realize how important the current activities are.I am sure that the number of such cases will increase, and I will write about them as soon as I find them.
