Case 18-2020: A 73-Year-Old Man with Hypoxemic Respiratory Failure and Cardiac Dysfunction

Abstract

Pr esentation of Case Dr. Lila M. Martin: A 73-year-old man was transferred to the intensive care unit (ICU) of an academic health center in Boston for acute hypoxemic respiratory failure in March 2020, 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 in his usual state of health until 6 days before this transfer , when a dry cough, fever, and worsening fatigue developed. Two days later, his symptoms had not resolved, and he presented to the emergency department at a local hospital. The temperature was 38.8°C, the blood pressure 94/62 mm Hg, the heart rate 91 beats per minute, the respiratory rate 12 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. On examination, he appeared well, and the lung sounds were clear. The white-cell count was 5600 per microliter (reference range, 4800 to 10,500); 56% of the cells were neutrophils and 33% were lymphocytes. A nasopharyngeal swab was submitted to the Massachu-setts State Laboratory for nucleic acid testing for SARS-CoV-2 RNA. Tests for influenza A and B viruses and respiratory syncytial virus were not performed owing to a statewide shortage of nasopharyngeal swabs. Dr. Diana Litmanovich: Computed tomography (CT) of the chest, performed without the administration of intravenous contrast material, revealed small (1 to 1.5 cm in diameter), rounded central and peripheral ground-glass opacities in both lungs (Fig. 1A). Dr. Martin: Oseltamivir was prescribed for the empirical treatment of influenza, and the patient was discharged from the emergency department and instructed to self-quarantine at home. During the next 4 days, his symptoms persisted; when dyspnea developed, he contacted his primary care physician and was referred back to the emergency department at the local hospital. The temperature was 38.6°C, the blood pressure 158/91 mm Hg, the heart rate 108 beats per minute, the re