Case presentation
On July 12, 2020, a 56-year-old man with fever, severe shortness of breath, cough, and A+ blood group was admitted to M-ICU at the Ghaem Hospital in Karaj, Iran. He was a pediatrician. A polymerase chain reaction (PCR) test had been performed before he was admitted. The PCR findings indicated that the patient was positive in terms of the presence of SARS-COV-2 at the 24.5 cycle threshold (CT) value. The patient had a history of high blood pressure and had consumed the Valsartan tablet 80 mg. Generally, his medication regimen had included Hydroxychloroquine sulfate, Lopinavir/Ritonavir, Remdesivir, ReciGen (interferon beta-1a), Naproxen, Dexamethasone, Convalescent plasma, and Albumin during the period of hospitalization. On the first day of admission, primary laboratory findings revealed the elevated level of white blood cells (WBCs, 20900/microliter) with a high count of neutrophil (91% of WBCs), impaired liver function; (SGPT or ALT, 127 U/L), acute inflammation; (ESR, 30 mm/hr, not shown in Table 1), negative D-Dimer, and increased fibrinogen (403 mg/dL, not shown in Table 1). On the 2nd post-admission day, lactate dehydrogenase (LDH, 477 U/L, not shown in Table 1) test was performed. Also, a drastic decrease was seen in WBCs count. The enzyme-linked immunosorbent assay results (ELISA) indicated that both SARS-COV2 IgM and SARS-COV2 IgG were negative. Renal function was normal (Table 1). On the next day, the level of total bilirubin was upper than the reference range. Furthermore, the coagulation system was normal. On this day, the patient received fresh frozen plasma (FFP). On the 5th post-admission day, the patient’s partial pressure of oxygen (PO2) and oxygen saturation (SO2) were lower than normal, and his pulmonary capacity had reduced. One day later, the result of the hepatitis B surface antigen (HBsAg) test was reported as non-reactive or negative. Explicitly, the level of PO2 reached under 40 mmHg. Meanwhile, renal function was disrupted. A portable chest X-ray (CXR) revealed that the image size of the heart and mediastinum was normal. Moreover, the ground-glass opacity (GGO) was seen in peripheral areas of both lung sides, especially the basal zone. There were no manifestations in the bony thorax. On the 7th post-admission day and the next day, the patient received Morphine Sulfate 10 mg/ml solution by injection each day. Concerning the result of the CXR, the diffused GGO in hemithorax was proved, and pleural effusion. Finally, the patient passed away due to respiratory failure, impaired liver function; (SGPT/ALT, 2500 U/L, SGOT/AST, 4200 U/L), and renal dysfunction. The GGO was apparent in peripheral areas of both lung sides, and lateral sinuses were closed. Drastically, the patient’s WBCs count had increased on this day (Table 1).