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 ).