A 95-year-old Patient With Unexpected Coronavirus Disease 2019 Masked by Aspiration Pneumonia

A Case Report

Francesco Spannella; Letizia Ristori; Federico Giulietti; Serena Re; Paola Schiavi; Piero Giordano; Riccardo Sarzani


J Med Case Reports. 2020;14(82) 

In This Article

Case Presentation

A 95-year-old Caucasian woman was admitted to our Internal Medicine and Geriatrics Department on 2 March 2020. Her symptoms started on 26 February 2020 with onset of fever, cough, and vomiting, which led to her hospitalization in the main general hospital of the town in which she lived, where an initial diagnosis of aspiration pneumonia was made. In the diagnostic workup, she had several comorbidities including arterial hypertension, chronic heart failure, paroxysmal atrial fibrillation, dyslipidemia, stage G4 chronic kidney disease, vascular dementia with deconditioning syndrome, sacral pressure ulcers, and known dysphagia. Home medications were the following: furosemide 25 mg, amiodarone 200 mg, warfarin 5 mg, and pantoprazole 20 mg.

She lived at home with her son and a caregiver. At initial interview, both of them denied any travel to areas of high transmission for COVID-19 or contact with people coming from these areas (there was no clear epidemiological link). She had been vaccinated for the seasonal influenza virus. She was almost totally dependent on both basic activities of daily living (BADL) and instrumental activities of daily living (IADL). On admission, she had fever (39.1 °C) and acute respiratory failure requiring oxygen supplementation with arterial oxygen saturation (SaO2) of 93% with fraction of inspired oxygen (FiO2) of 40%, altered mental status, tachycardia with heart rate of 94 beats per minute (bpm), and high blood pressure (160/80 mmHg). Other relevant features on physical examination were bilateral lung crackles and peripheral pitting edema. On day 1 after admission, a chest computed tomography (CT) scan was performed to better characterize the admission chest X-ray findings (bilateral patchy shadowing, Figure 1), showing multiple bilateral ground glass opacities (GGOs), crazy-paving pattern, and bilateral lobular and sub-segmental areas of consolidation (mainly focused in lingular segment of left lung and inferior lobe of bilateral lungs) (Figure 2). Laboratory tests on admission (Table 1) showed a normal white blood cell (WBC) count with lymphopenia, high C-reactive protein, and slightly increased serum levels of pro-calcitonin. D-dimer and aminotransferase levels were within normal range, whereas N-terminal pro-B natriuretic peptide (NT-proBNP) levels were elevated. Pneumococcal and Legionella urinary antigen tests were negative. Blood and urine cultures were negative. Bronchoalveolar lavage collected from our patient on admission tested positive for methicillin-sensitive Staphylococcus aureus (10,000 CFU/ml) and Citrobacter werkmanii (100,000 CFU/ml), both sensitive to piperacillin-tazobactam. Based on this information, the empiric antimicrobial therapy started on admission with piperacillin-tazobactam was maintained. A bedside swallowing assessment was also performed, confirming dysphagia to both liquids and solids. During the hospitalization, she had two episodes of high-rate atrial fibrillation (160 bpm) treated with metoprolol and amiodarone, with restoration of sinus rhythm. After hemodynamic stabilization, she was transferred to our ward for geriatric management.

Figure 1.

Chest X-ray performed on admission (single supine anteroposterior view) showing bilateral patchy shadowing

Figure 2.

Chest computed tomography performed on day 1 after admission showing multiple bilateral ground glass opacities, coupled with crazy-paving pattern, as well as bilateral lobular and sub-segmental areas of consolidation. Axial view (left); coronal view (center); sagittal view (right)

A real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) assay for SARS-CoV-2 was not performed on admission, due to the lack of previous history of travels or close contact with a confirmed or probable case of COVID-19 in the previous 14 days, according to the epidemiological criteria disclosed by health authorities at that time (World Health Organization's criteria of suspicion for SARS-CoV-2 infection). However, after her admission at our ward, the persistence of severe hypoxemia, fever (37.6 °C), cough, and high C-reactive protein (14.68 mg/dl) coupled with reduced pro-calcitonin (0.14 ng/ml) after appropriate antibiotic therapy, prompted us to collect nasopharyngeal and oropharyngeal swabs on 3 March 2020 even in the absence of epidemiological criteria. The rRT-PCR assay tested positive for SARS-CoV-2 infection. She was then isolated and managed by a dedicated health care team, according to the protocol of our hospital. After an initial period of clinical stability with high-flow oxygen, she required continuous positive airway pressure in order to maintain adequate oxygenation. On 25 March 2020 she died of cardiac complications.