Clinical summary
A 75-year-old Japanese man was found to be infected with severe acute
respiratory syndrome-coronavirus-2 (SARS-CoV-2) by polymerase chain
reaction (PCR) test. He lived together with his wife and daughter, and
his daughter first developed Coronavirus infectious disease 2019
(COVID-19). Three days later, he and his wife appeared to be
PCR-positive for the virus. He was under medication for diabetes
mellitus (DM), gout, hypertension, and atrial fibrillation. In addition,
he underwent an operation for squamous cell carcinoma, two months before
the PCR test. His status was pT2aN2M0, pStageⅢa, and he showed a good
post-operative performance.
Three days after the PCR test, he developed a fever, and was
hospitalized (day 1). His SpO2 was 95% with oxygen,
2L/min by nasal canula. The image of thoracic computed tomography (CT)
is presented in Figure 1a. Anti-viral therapy with remdesivir
(100mg/day) was started, but his fever did not go down. On day 5, CT
revealed the apparent pulmonary fibrosis with a crazy-paving pattern,
characteristic for COVID-19. Oxygen was supplied with nasal high frow
(NHF), 40L, FiO2 55%. Anti-inflammatory therapy was
started with dexamethasone (6.6mg/day). However, with worsened
respiratory condition, FiO2 70-80% was required to keep
SpO2 90-95%. Invasive mechanical ventilation was
seriously considered, but not performed due to unwillingness of the
patient and his family. On day 10, IL-6 inhibitor, tocilizumab (680mg)
was administered, then SpO2 was gradually improved. Since
FiO2 was decreased to 40-60% to keep
SpO2 92-95%, NHF was changed to the biphasic positive
airway pressure system (BIPAP). However, on day 15, bacterial
co-infection was suspected with the white blood cell (WBC) count,
23600/µl. Increase in FiO2 was again required. and
treatment with meropenem (2g/day) was started. Pulse therapy with
prednisolone (1000 mg x 3 days) was also done. On day 21, he was
suddenly deteriorated with bradycardia and low blood pressure, and
passed away. Just before the autopsy, the final PCR test still revealed
the presence of SARS-CoV-2 in the nasopharyngeal swab. The clinical
course is summarized in Figure 1.