Case Report 2
A 59-year-old Hispanic male patient with a medical history of hypertension, obesity, and poorly controlled diabetes mellitus (last HbA1c was 13%) presented to the emergency department for fever of 20 days duration and worsening cough with expectoration, as well as progressive respiratory distress. On admission, his vital signs were a blood pressure of 144/83 mmHg, heart rate of 74 beats per minute, respiratory rate of 50 breaths per minute, O2 saturation of 40% (room air), and temperature of 38 °C. On physical examination, he was found to be febrile, somnolent, and polypneic, with marked respiratory effort. Emergency orotracheal intubation and transfer to the intensive care unit were necessary.
Initial screening showed thrombocytopenia (platelet count 138 × 103 cells/μl), leukocytosis (WBC 15,760 cells/ml, 90% neutrophils) with lymphopenia (6.20% lymphocytes), elevated transaminases (ALT 1507.4 IU and AST 3049.7 IU), elevated D-dimer (44,066 μg/ml), and negative RT-PCR SARS CoV-2 test. Chest X-ray showed extensive interstitial infiltrates in both lung fields (Figure 1b). Considering the progressive decrease in total platelet count as well as gradual lymphopenia (Figure 2), a dengue IgM/IgG test was conducted and was positive, while the dengue PCR-RT test was negative. According to radiographic findings and respiratory involvement, the RT-PCR test for SARS CoV-2 was repeated on two more occasions, with negative results. Therefore, IgG antibodies for SARS CoV-2 were assayed and were positive.
Positive serology for both SARS CoV-2 and dengue virus confirmed coinfection, so it was considered that he had probably entered a late stage of the disease. Steroid management was indicated according to COVID-19 management guidelines, in addition to pronation cycles, to which he presented poor response and persistent hypoxemia. During his stay in intensive care, he presented multiple complications, such as acute pulmonary embolism, with signs of secondary thromboembolic pulmonary hypertension, bacterial superinfection in his lungs by Klebsiella pneumoniae, and Akin III acute renal failure. Computerized tomography angiography of the chest was performed, which confirmed acute pulmonary thromboembolism of multiple bilateral lobar and segmental bilateral branches with signs of secondary pulmonary hypertension and pulmonary changes suggestive of organizing pneumonia secondary to viral infection (Figure 3). Details of the clinical description of the coinfection are presented in Table 1. The patient remained in the ICU for COVID-19, bacterial superinfection, and dengue with alarm signs for 63 days. His progression was slow, showing progressive clinical deterioration. He required prolonged mechanical ventilation and vasopressor management until he finally died.
J Med Case Reports. 2021;15(439) © 2021 BioMed Central, Ltd.