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.