The case:
This is a 39-year-old male with no previous medical issues presented with 2 days history of fever and dry cough which was associated with shortness of breath, review of systems was unremarkable other than what mentioned above. On physical exam the patient was in respiratory distress, febrile with temperature of 38.5 C, and he was requiring 2 liters of oxygen via nasal cannula to maintain oxygen saturation above 94%, Heart rate was 110 and blood pressure was 120/75, chest auscultation was positive for bilateral crackles, abdominal exam was unremarkable with no palpable organs.
Initial investigation showed high white blood cells with count of 68.8*10^3 (4-10*10^3), Hemoglobilin level was 10.9gm/dl, MCV 84.8 and platelets count of 629*10^3 with normal liver and kidney function, and the patient tested positive for COVID 19, XR chest showed right upper and left lower lung zones of infiltrates and the patient was admitted as case of COVID 19 pneumonia, further evaluation including peripheral smear showed normochromic normocytic anemia. Severe leukocytosis, Slight anis-poikilocytosis, with occasional NRBCs, Leukocytes shift to the left with few circulating blasts, Slight increased platelets and the picture is consistent with CML, Ultrasound abdomen showed Hepatosplenomegaly with liver size of 22.2 cm and spleen of 17.7 cm ,BCR/APL testing from peripheral blood sample was consistent with a rearrangement of BCR/ABL1 in 96.5 % of nuclei so the patient was diagnosed with chronic myeloid leukemia.
During hospitalization the patient was stared on COVID 19 treatment as per our hospital protocol so he was started on azithromycin, hydroxychloroquine, ceftriaxone, oseltamivir and lopinavir/ritonavir, in addition to that he was started on hydroxyurea due to high WBC count, despite that his oxygen requirement was increasing chest X-ray showed bilateral infiltrate as illustrated in (image1), on third day of admission patient was tachypneic and desaturating on 15 liters of oxygen via non rebreathing mask so he was intubated and admitted to the intensive care unit and he was started on methylprednisolone with piperacillin/tazobactam and post intubation X ray chest is shown in (Image2) which worsening of the bilateral infiltrate, with endotracheal tube(white arrow), central line (yellow arrow) and NG tube (black arrow). And on the following 3 days he received 2 doses of tocilizumab, few days later the patient condition started to improve, and he was extubated on day 9, after that his condition continued to improve during the subsequent days and he was started on imatinib as upfront.