Dr. Kathy M. Tran: A 76-year-old woman was admitted to this hospital because of confusion and hypoxemia during the pandemic of coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The patient had been well until 6 days before this admission, when nasal congestion developed, with no fever or cough. One day before this admission, she called her primary care physician, who recommended fluticasone nasal spray and nasal rinses and asked her to follow up by telephone in 2 days. However, the next day, the patient’s son visited the patient and found her to be confused and incontinent of urine and stool. Emergency medical services were called, and when they arrived at the patient’s home, the oxygen saturation was 87% while she was breathing ambient air. The patient was transported by ambulance to this hospital.
In the emergency department, the patient reported chills but no fever, cough, shortness of breath, sore throat, chest pain, or dysuria. Additional information was obtained from the patient’s daughter and son by telephone. There was a history of asthma, diabetes, hypertension, hyperlipidemia, osteoporosis, and psoriasis. Medications included atorvastatin, aspirin, hydrochlorothiazide, losartan, insulin, metformin, glipizide, citalopram, acetaminophen, cholecalciferol, folate, fluticasone nasal spray, and topical betamethasone and fluocinonide. Lisinopril had caused a cough; penicillin and sulfa drugs had caused hives. The patient was widowed and lived in an assisted-living facility where multiple residents had recently received a diagnosis of Covid-19. She did not smoke tobacco or use electronic cigarettes, alcohol, or illicit drugs. Her family history included diabetes and cancer in both her father and her brother; her daughter and son were well.
The temperature was 38.8°C, the heart rate 94 beats per minute, the blood pressure 176/55 mm Hg, the respiratory rate 24 breaths per minute, and the oxygen saturation 94% while the patient was receiving supplemental oxygen through a nasal cannula at a rate of 2 liters per minute. On examination, the patient appeared ill and was lethargic. She was alert and oriented but unable to recall events from earlier in the day. The lungs were clear on auscultation. The white-cell count was 7690 per microliter (reference range, 4500 to 11,000); the blood d-dimer level was 3592 ng per milliliter (reference range, <500). Urinalysis results were normal. Nucleic acid testing of a nasopharyngeal swab was negative for influenza A and B viruses and respiratory syncytial virus but was positive for SARS-CoV-2. Other test results are shown in Table 1.
Dr. John Conklin: On radiography of the chest (Figure 1A), patchy airspace opacities were present in the left upper lobe and surrounding the hilum. On computed tomographic (CT) pulmonary angiography of the chest (Figure 1B, 1C, and 1D), performed after the administration of intravenous contrast material, multifocal consolidative and ground-glass opacities, including some with rounded morphologic features, were present in both lungs. These findings have been commonly reported with Covid-19 pneumonia, although other processes, such as influenza pneumonia and organizing pneumonia, may have a similar appearance on imaging.1 There was no evidence of pulmonary embolism.
Dr. Tran: Acetaminophen and empirical ceftriaxone, azithromycin, and hydroxychloroquine were administered. Because the patient had acute respiratory failure and Covid-19, goals of care were discussed with her adult children by telephone; the patient was unable to participate meaningfully in the discussion because of confusion. She had recently expressed to her primary care doctor that she would “not want to be on a breathing machine if something were irreversible.” A status of “do not resuscitate and do not intubate” was assigned.
During the next day, intermittent episodes of fever occurred, with temperatures as high as 40.3°C, and delirium and hypoxemia worsened. On the third hospital day, new atrial fibrillation with a rapid ventricular response developed, and metoprolol and furosemide were administered.
On the fourth hospital day, the respiratory rate was 36 breaths per minute and the oxygen saturation was 90% while the patient was receiving supplemental oxygen through a nonrebreather mask at a rate of 15 liters per minute. She appeared to be in distress, with increased work of breathing. Goals of care were again discussed with the patient’s family, and a status of “comfort measures only” was assigned. The patient died 36 hours later. After discussion with the family, an autopsy was performed.