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.