Clinical report and treatment strategies
A 34 year old male presented on June 1, 2020 with self-reported
SARS-CoV2-like symptoms of more than 10 days including fever, reduced or
lack of smell, lethargy and bone pain1 . The patient
had self-medicated with Moxifloxacin (400mg/d), Paracetamol (1000mg/d)
and Antihistamine. Upon arrival at the hospital, the patient wanted a
antiviral therapy for SARS-CoV2 infection but we refused as no patent
SARS-CoV2 symptoms such as fever were obvious although there were slight
symptoms of throat allergy but no cough. Chest X-ray was normal and
complete blood count showed slightly elevated WBC count. We prescribed
Clarithromycin (500mg/od) and Montelukast sodium (10mg/od) for 6 days
but the patient returned after three days with high fever (104F),
dizziness, lethargy and fatigue. Given that local shortages of antiviral
medicines, he was prescribed Artemether/Lumefantrine 80/480mg as Gen-M
(Antimalarial drug), Ceftriaxone 1g, Dexamethasone IV for three days
along with Paracetamol 100mg and Montelukast sodium
10mg/od2 . This combination of medicines has proven
highly effective in our attended pool of patients with mild or moderate
symptoms of SARS-CoV2. However, in this case, the symptoms progressed
over the next six days with X-ray examination showed complete chest
congestion and damaged lungs. The patient also reported difficulty in
breathing, which exacerbated over the next three days where we observed
a drop in oxygen saturation to below 70%. The patient refused to stay
in the central COVID-19 facility in our hospital, and we therefore
advised home isolation with medication of third generation
antibacterial Gemifloxacine 320mg and Montelukast sodium 10mg. Cough
syrup and oxygen was also supplied and the patient also self-medicated
with natural herbs for sore throat relief.
The patient was brought back to hospital after two days, almost
unconscious, bluish skin (probably due to low oxygen) and blood
clotting, inverted nails, diarrhea and difficulty in breathing and
speaking. Oxygen levels dropped to below 25%, we referred him to the
central COVID-19 facility where he was kept on continuous supply of
oxygen at an extreme care unit for several days then moved to the normal
isolation, still with continuous oxygen. He was prescribed with
paracetamol IV, Ceftriaxone 1g/ IV, Dexamethasone IV twice a day and
Azithromycin 0.5g/IV, Omeprazole 40mg IV once a day, Enoxaparin sodium
IM as blood thinner2,3. In addition, Nitazoxanide was
prescribed for three days to control viral diarrhea. Azithromycin IV was
discontinued because of severe reactions including vascular pain, cold,
shivering and neck twisting, and it was replaced with oral Azithromycin
500mg/OD for two weeks. However, we found that his serum has extremely
high level of inflammatory and liver function markers. The patient also
reported severe insomnia and we prescribed Alprazolam (0.5mg). Moreover,
the patient was also advised to take Vitamin D3 5000IU, Multivitamins
and Montelukast sodium 10mg daily. He was kept on the same treatment for
18 days then discharged from hospital after having satisfactory reports.
He was advised to take complete bed rest for two weeks since his muscles
were weak and body weight was reduced. Upon his discharge from the
hospital, as part of home treatment he was prescribed tapering doses of
Prednisolone; 20mg od 5 days, 10 mg od 5 days, 5mg od 5 days, together
with Moxifloxacin 400mg od 5 days, omeprazole 40mg od for two weeks,
multivitamins and Alprazolam 0.5mg for one month. Patient felt
difficulty in breathing and chest pain after completing the prescribed
course of Prednisolone. Upon re-examination, chest X-ray indicated
inflammation in the lungs and pulmonary edema. This condition prompted
us to advise a combination of steroidal anti-inflammatory drugs
Betamethasone and Spiromide 20mg daily for one month, which helped the
patient recover from fibrosing lung disease, bronchoconstriction, lung
inflammation and pulmonary edema. However, he faced continuous breathing
difficulties and failed to walk freely, taking three months to achieve
symptomatic relief from this illness. Apart from physical anomalies, the
patient also developed psychiatric stress symptoms in the post
hospitalization period.
After 8 months, the patient resumed normal daily life activities and was
asymptomatic except for loss of smell sensitivity. Examination of blood
for the presence of antibodies showed strong signals for SARS-CoV2 IgG,
indicative that patient had developed immunity against COVID-19.
The patient also volunteered to receive COVID-19 (Sinovac from
SinoPharm) vaccination and interestingly, upon administration, showed a
short term reaction with headache, fever, nausea and restlessness
lasting for 12-24 hours. This fast reaction to the vaccine suggests that
available IgG antibodies in his blood strongly responded to high dose of
inactive pathogens.
In conclusion, despite having extensive care and treatment, the patient
initially showed mild to moderate symptoms followed by severe SARS-CoV2,
as previously described for another patient4 .
Survival rates for such cases are extremely low especially once oxygen
saturation levels fall below 25%. Based on this extreme case, we
hypothesize that second and third generation antibacterial drugs
represent good options for coping with opportunistic bacterial
infections accompanying SARS-CoV2 infection along with supplemental
oxygen therapy and SAIDs. Therefore, we believe timely treatment to
prevent opportunistic bacterial infections provides time for natural
immunity development against SARS-CoV2 as we observed in the
current patient. Moreover, a long-term care is required for patients
with severe acute respiratory syndrome (category three SARS-CoV2). It is
highly recommended that a combination of steroidal anti-inflammatory
drugs be given to patients for a month or longer for complete recovery.
Moreover, complete bed rest is necessary along with 30 minutes daily
walk and physiotherapy for at least for two weeks.