Case Report
A 46-year-old male patient, who is not known to have previous chronic
medical conditions, presented to the emergency department complaining of
feeling of hotness, cough, and loss of smell of 4 days duration. On
presentation, he was conscious, alert, and oriented to time,
place, and person. He was febrile (Temperature of 38.9 C°), tachycardic
with heart rate of 104 bpm, tachypnoeic with a respiratory rate of 28
breaths per minute, Blood Pressure was 107/81 mm Hg and O2 saturation on
room air was 97%.
On physical examination, pupils were equal in size and reaction to
light. Chest auscultation showed clear breath sounds bilaterally with
normal S1S2 and no murmurs. Abdomen was flat, soft, with no tenderness
or guarding. Extremities: no bipedal enema, bilateral full and equal
pulses. GCS 15/15, no neurologic deficits.
Blood investigations revealed WBC to be 5.7×109 L, with low lymphocytic
count 0.7*103 uL Haemoglobin 15.3 g/dl, platelet count
122×109 L, Urea 3.04 mmol/l, creatinine 89 umol/L, CRP
140 mg/L, and normal electrolytes.
Chest x-ray demonstrated multiple pneumonitic patches seen in both lung
fields which were suggestive of viral pneumonia. Nasopharyngeal swab for
COVID-19 PCR was positive. Based on the above-mentioned work up the
patient was admitted as a case of COVID-19 pneumonia. His condition
deteriorated the next day of admission, and he was more tachypnoeic
requiring O2 supplementation by nasal cannula.
He was transferred to Medical intensive care unit (MICU) for
observation. As his oxygen requirements increased, he was started on
none rebreathing mask (NRM) then switched into non-invasive ventilation
(CPAP). Despite this, his condition deteriorated further that required
endotracheal intubation and he was started on mechanical ventilation.
He received a treatment protocol for COVID-19 infection according to our
hospital protocol in accordance with the international guidelines at
that time, which was as the following:
1-Hydroxy-Chloroquine 400 mg once daily X 10 days
2-Azithromycin 500 mg X 7 days
3- Methyl prednisolone 40 mg IV q12hr for 5 days.
4- Tocilizumab 600 mg IV 2 total of 2 doses (8 days between the 2 doses)
He was kept on enoxaparin for DVT prophylaxis, and the dose was adjusted
according to his clinical situation with monitoring of Anti Xa.
Furthermore, he received convalescent plasma.
During this time, the platelet counts had dropped to as low as
92*103 for 2 days then improved to normal levels. The
INR was normal, and heparin induced thrombocytopenia (HIT) test was
negative. No noticeable overt bleeding episodes.
He was kept on mechanical ventilation and the ventilator setting was
adjusted. Proning was required three times and his condition was
gradually improving. Sedation and muscle relaxation were tapered off and
after 18 days he was successfully extubated.
After extubation, the patient was unable to move his four
limbs, but he had intact level of consciousness. Physical examination
revealed a power of 1/5 in all muscle groups of upper and
lower limbs, bilateral lower limb wasting with hyporeflexia, no
fasciculations, plantar reflex was negative, and sensation was intact.
As an evaluation of his quadriplegia, brain& spinal cord MRI (Figure1)
were done and showed late subacute hematoma involving the corpus
callosum, with a background of numerous supra and infratentorial foci of
microbleeds. Cervicodorsal spinal cord MRI was unremarkable.
Accordingly, enoxaparin was stopped on the same day.
Neurosurgery team was consulted regarding any possible therapeutic
intervention for the subacute callosal hematoma. Since the hematoma was
not causing any mass effect and the fact that it was subacute with no
associated IVH, no neurosurgical intervention would be of benefit.
Neurology team evaluation was suggesting critical illness
neuropathy/myelopathy as a cause of the quadriplegia rather than the
hematoma itself. Due to isolation precautions nerve conduction study nor
electromyography could be done.
Next day, he was noted to have persistent tachycardia with HR ranging
100-120 BPM. CT pulmonary angiogram (Figure 2) was done and showed two
pulmonary thromboembolisms. The pulmonary thromboembolism involved the
anterior branch of the left main pulmonary artery extending to
sub-segmental branches and the posterior basal segmental and
sub-segmental branches of right lower lobe pulmonary artery.
Considering the intracranial bleeding, he was commenced on heparin
infusion with close monitoring of the neuro vitals. Then, he was
switched into therapeutic low molecular weight heparin. Follow up head
CT scan (Figure 3) demonstrated the same subacute corpus callosum
hematoma, with no acute changes or bleeding.
COVID-19 PCR swab was repeated twice and both results were negative.
Patient was tapered off O2 supplementation and he maintained an
acceptable O2 saturation on ambient air.
After discussing the case with haematology team, with consideration to
the patient condition, the patient was given therapeutic dose enoxaparin
subcutaneously for 3 months as a case of provoked pulmonary
thromboembolism.
Extensive physiotherapy sessions were started with gradual and
noticeable improvement in the muscle groups power.
Patient was being treated as an inpatient for 2 months, then continued
physiotherapy in rehabilitation institute for another 1 month. On
discharge, muscle power was 4/5 & he was independent in most of the
activities of daily living, with need for assistance in using stairs
only.
On further follow up, patient continued to attend outpatient
physiotherapy sessions on weekly basis. He completed 3 months enoxaparin
for anticoagulation, no reported bleeding episodes.
The Patient is now functioning independently, and he returned to his
work.