Case description
A 49-year-old man came to the Emergency Department after the first wave of Coronavirus because of dyspnea, fever and arthralgia. He is a farmer and his medical history includes type 1 diabetes and asthma. General examination was normal except lung crackles. His temperature was of 38.5°C with an oxygen saturation of 95% to ambient air. Laboratory tests revealed a C-reactive protein level of 31 mg/l and a natremia of 122 mmol/l. CK levels were in standards. Computed tomography of the chest showed an interstitial pneumonia suspected of SARS-CoV-2 infection and the patient was hospitalised in the Covid-19 ward of the hospital (Figure 1 ). Later, viral serologies and bacterial cutures were all negative, including screening HIV and hepatitis. An antibiotherapy by amoxicillin/clavulanic acid was started and since the patient needed oxygen supplementation, he was admitted to the Intensive Care Unit (ICU) after a week of hospitalisation. An escalation therapy by piperacillin/tazobactam and doxycycline was done with oxygen therapy of 8 litres per minute by mask but intubation was never required. Bronchoalveolar lavage showed a lot of macrophages and a low CD4/CD8 ratio with bacteriological and Pneumocystis Jiroveci research negatives. Antinuclear antibodies (ANA) were positives with a 1/2640 titre and anti-RNP and anti-JO1 identification. IPAF was established and a treatment with corticosteroids and mycophenolate mofetil (MMF) was started in the ICU. The patient was then transferred to the Internal Medecine Department for his management. Unfortunately, his need of oxygen did not decrease so that supplemental oxygen with 8 litres per minute was required for oxygen saturation of 92% in a resting condition. He desaturated with exercises at 80% of saturation. Pulmonary function tests were unrealisable at that time. After a month without improvement, the patient received rituximab (Rtx) as salvage therapy and finally got better. After a few days, his need of oxygen decreased and he went to a rehabilitation centre for recovery. At a 4-month follow-up, he no longer needed oxygen and control computed tomography of the chest showed significant improvement (Figure 2 ).