Results
Our case (Case R, Figure 1) was a 77-year-old male with hypertension and dyslipidaemia, a diagnosis of cutaneous B-cell lymphoma in remission, a previous stroke, and chronic obstructive pulmonary disease associated to mild interstitial lung disease without exacerbation nor need of supplemental oxygen. His first positive SARS-CoV-2 RT-PCR was on July 28, 2020 when he had a mild infection with fever without developing pneumonia or other complications. Hospital admission was not required. SARS-CoV-2 serology was not performed at that time.
On September 1, he was admitted to the hospital due to an acute obstructive cholangitis secondary to choledocholithiasis that was removed by endoscopy. The patient received piperacillin-tazobactam. After the endoscopic procedure, he developed mild acute pancreatitis, hemobilia, and acute kidney injury related to acute tubular necrosis. In addition, he developed catheter-related Enterococcus faeciumbacteraemia successfully treated with vancomycin. During this time, he obtained two negative SARS-CoV-2 RT-PCR tests (September 1 and 14, Figure 1).
On Day 23 following admission, extensive bilateral lung opacities were identified in a control abdominal computed tomography (CT). After these unexpected radiological findings, SARS-CoV-2 RT-PCRs were performed for two consecutive days, both positive (Ct 19, Ct 21). IgG SARS CoV-2 serology was negative (Figure 1).
Case R developed mild dyspnoea and hypoxemia (oxygen saturation of 92% at room air). He received remdesivir for five days and dexamethasone 20 mg once daily for four days. After a slight improvement, on Day 29, he developed fever and respiratory worsening. On Day 31, high-flow oxygen therapy and a single 400 mg dose of tocilizumab (IL-6 level: 226pg/mL) were administered. The patient was transferred to the ICU where he received full ventilatory support and continuous changing between prone and supine positions. However, the patient rapidly developed multiorgan failure with hemodynamic instability, mixed metabolic and respiratory acidosis, and renal impairment requiring continuous renal replacement therapy. Body CT scan revealed non-specific colitis and worsening of the bilateral pulmonary opacities with pleural effusion. A colonoscopy ruled out ischemic colitis. Despite all therapeutic interventions, the patient developed refractory multi-system organ failure and finally died on Day 34. Retrospectively, we recovered three sera specimens (from days 23, the day the nasopharyngeal RT-PCR result was positive, 27, and 30) and all were positive for SARS-CoV-2 RT-PCR. Clinical outcomes are shown in Figure 1.