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

Discussion and Conclusions

We described a case of a 95-year-old woman with several pre-existing comorbidities who was affected by COVID-19 pneumonia masked by aspiration pneumonia. If we were not in a SARS-CoV-2 pandemic, this would have been a classic case of aspiration pneumonia in a patient with vascular dementia and dysphagia. However, it turned out to be a case of COVID-19 pneumonia after the initial diagnosis. In our opinion, this case report highlights several important aspects of COVID-19.

On 2 March 2020, the date of admission to our ward, 1835 individuals had tested positive for SARS-CoV-2 at rRT-PCR assay in Italy, almost all concentrated in the Lombardy region, and only 35 cases had been tested positive in our smaller region (Marche), mainly in the northern part and not in our city.[8] Our patient was a bedridden older individual with very limited social contacts, who lived at home with her son and a caregiver who did not report any epidemiological link. Both individuals were asymptomatic. These findings probably indicate that SARS-CoV-2 had been circulating within the Italian population for some time previously, and they support the hypothesis that the virus was spreading undetected, probably through asymptomatic people. There is evidence that SARS-CoV-2 transmission can occur from asymptomatic or mildly symptomatic individuals.[9,10] Some authors, using a model inference framework, estimated that 86% of all infections in China were undocumented prior to the travel restrictions of 23 January 2020, suggesting that undocumented infections might have been the source for 79% of documented cases.[11] This hypothesis could also be true for Italy. Findings from a population study in Vo' Euganeo (Veneto region, Italy) showed that the majority of people infected with SARS-CoV-2 (50–75%) were asymptomatic, probably representing "a formidable source" of contagion.[12]

Retrospective studies on Chinese patients hospitalized for COVID-19 showed that the disease has different features in older patients. In fact, they had higher disease severity compared to young and middle-aged patients, with higher Pneumonia Severity Index (PSI) score, higher proportion of multiple lobe involvement, higher C-reactive protein, and lower lymphocytes count.[13] Symptoms at onset of COVID-19 disease often include cough, dyspnea, and fever or measured temperature ≥ 38 °C. However, many older patients with pneumonia often exhibit atypical symptoms and signs compared to adults.[14] Older patients with pneumonia are often afebrile, with normal WBC count, while acute changes in functional and mental status are highly prevalent. Dyspnea could also be difficult to assess, given the limited physical activity of these individuals.[14] Given the possible atypical presentations, the diagnosis of pneumonia in older patients may be challenging. In a viral pandemic era, the clinical picture may be even more complicated. In our case, the diagnosis of aspiration pneumonia was supported by the presence of dysphagia, elevated C-reactive protein, and the findings at bronchoalveolar lavage. On the other hand, some other typical laboratory parameters of COVID-19 were also present, such as the increase in C-reactive protein-to-procalcitonin ratio, and absolute lymphopenia with normal WBC count.[15] However, these parameters in older patients may be difficult to interpret. For example, lymphopenia is very common in hospitalized older patients, representing a typical laboratory marker of frailty.[16]

Radiographic findings of aspiration pneumonia include infiltrates in gravity-dependent lung segments (superior lower lobe or posterior upper lobe segments, if the patient is in a supine position during the event, or basal segments of the lower lobe, if the patient is upright during the event).[6] On the other hand, GGOs and bilateral patchy shadowing, mainly in the lower lobes, are the most common patterns on chest CT in patients with COVID-19.[2,17] In fact, these CT abnormalities, not typically correlated to a diagnosis of aspiration pneumonia, were found in our case. The chest CT findings (multiple bilateral GGOs coupled with crazy-paving pattern and areas of consolidation) indicated that the COVID-19 had been present for at least approximately 5–7 days before the examination.[18] However, at that time, the experience of radiologists in interpreting and detecting COVID-19 pneumonia may have been limited by the absence of COVID-19 pneumonia spreading in our district. Furthermore, the interpretation of radiological findings can be complex in older patients.[19] In fact, a chest X-ray is often inconclusive in older patients with suspected acute lower respiratory infection.[20] At the same time, it could be difficult, even at a CT scan, to recognize the suspected pulmonary disease in the midst of the age-related changes of lung parenchyma and the several comorbidities that act as confounders.[19] For example, GGOs, a typical feature of COVID-19, have not been linked to age-related changes, but may be found in congestive heart failure, a very common condition in hospitalized older patients.[21] Our patient had high NT-proBNP levels on admission, indicative of decompensated heart failure. This finding is highly prevalent in older patients admitted for lung and other infections, but without an admission diagnosis of heart failure, and it predicts in-hospital mortality.[21,22] The pro-calcitonin levels on admission (> 0.25 ng/ml) and the results of bronchoalveolar lavage probably indicated a bacterial infection,[23] which further complicated the radiological picture of chest CT in our patient. The clinical picture may be further complicated by the low sensitivity of the rRT-PCR assay for SARS-CoV-2 tested by nasopharyngeal and oropharyngeal swabs.[24]

During hospitalization, two paroxysms of high-rate atrial fibrillation occurred, which is a negative prognostic factor in COVID-19, together with both high NT-proBNP and troponin I levels.[25] This testifies how viral infection can worsen stable cardiovascular comorbidities, although direct myocardial damage due to SARS-CoV-2 has also been documented.[26,27] Pre-existing conditions, especially cardiovascular and kidney diseases, are more prevalent in older patients with severe COVID-19 compared to patients with milder disease.[2,28] These patients often die due to the worsening of these pre-existing conditions after the SARS-CoV-2 infection, resulting in multiple organ failure, just like other severe infections. The mortality rate of patients with acute kidney injury and COVID-19 illness is four times higher than in patients who do not have acute kidney injury.[29] Our patient had decompensated heart failure and died due to cardiac complications. There is still no consensus on the management of decompensated heart failure in older patients, particularly if affected by COVID-19. However, renin–angiotensin–aldosterone system blockers have been associated with lower in-hospital mortality in older patients admitted for medical conditions[30] and these drugs are also likely to be useful in the context of the COVID-19 pandemic.[31] Therefore, it is essential to evaluate carefully and treat comorbidities appropriately in patients with COVID-19, especially if older.[32]

In conclusion, this case report highlights how the diagnosis of COVID-19 pneumonia could be challenging in comorbid older patients, given the possible atypical presentation and the overlapping of other acute and chronic conditions that may complicate the interpretation of clinical, radiological, and laboratory findings. Not least, this case report shows that probably there were undocumented cases of infections with a wider spread of the virus before we became aware of it.