Case presentation
A 36-year-old male shepherd living in rural areas of Kermanshah, Iran,
presented to the emergency department with fever, myalgia, and abdominal
pain for 3 days prior to admission. His initial complaints did not
mention cough, dyspnea, hematemesis, melena, or hematuria. His medical
history was insignificant. Physical examination was normal, and his
vital signs were stable except for a low-grade temperature at admission.
His oxygen saturation was 96% on ambient air. Due to the COVID-19
pandemic and suspicion of SARS-CoV-2 infection, he was immediately put
in an isolation room, his nasopharyngeal swab specimen was sent for a
SARS-CoV-2 RT-PCR test, and he underwent a computed tomography (CT) scan
of the chest. The patient was started on favipiravir, dexamethasone, and
heparin. No pulmonary evidence of SARS-CoV-2 was detected in the lung
imaging, and his laboratory tests were in the normal range, except for
an elevated CRP level. However, within three days of hospitalization, he
developed progressive thrombocytopenia and increased elevated
transaminases and LDH. However, coagulation tests were not impaired,
fortunately.
Moreover, he developed a petechial rash on his buttocks. Anticoagulant
therapy was stopped, and platelet infusion was started for him.
Considering the summer season, the patient’s occupation, epidemiologic
features, bleeding syndrome, severe thrombocytopenia, and elevated liver
enzymes, this patient was highly suspected of CCHF. Hence, a blood PCR
test for CCHFV was also requested, and he was started on ribavirin with
dosing according to WHO recommendations and the national clinical
protocol of Iran for CCHF. The interesting issue was the result of his
positive PCR tests for both SARS-CoV-2 and CCHFV. The patient’s
condition improved, and was discharged 8 days after admission.