Case-report
On August 22,2022, a 27-year-old man presented to emergency room with severe abdominal pain, dyspnea, bloating and dyspepsia. The patient had a history of going to paddy two days ago, and two days before hospitalization he had experienced severe myalgia, headache and fever and had taken Diclofenac suppositories each 8 hours to control his fever. The day before hospitalization he had nausea and vomiting two times so he got serum injections.
On admission, the patient’s body Temperature was 38.2°, with an oxygen saturation at ambient air of 97%, the Respiratory rate was 25 cycles/min, the pulse rate was 130 beats/minute and his Blood Pressure was 120/80. The patient was not dyspneic while talking. In clinical examination no unusual pulmonary sounds was heard, no rash, jaundice, conjunctival pallor and conjunctival suffusion were seen. He could answer questions consciously and was mentally normal.
Laboratory tests did not show any Leukocytosis at first (white blood cell: 10000 lymphocytes/mm3), but Thrombocytopenia was seen at 71000 thrombocytes/mm3, and a normal serum creatinine level of 0.8 mg/dl (normal value,0.7-1.4 mg/dl). The patient’s Blood Urea Nitrogen level was 20 mmol/L, and Aspartate aminotransferase and Alanine transferase were at 69 and 244 U/L. His C-reactive protein was at 290 mg/L, and Troponin 1 was negative but the B-type natriuretic peptide was high at 9641 pg/ml (Table 1).
On the second day of admission, SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test was done on nasopharyngeal sample and was negative but the D-dimer was high at 1585.7 ng/ml (normal value, 0-800 ng/ml). High-resolution computed tomography (HRCT) of the chest was performed on admission and no unusual pulmonary symptom was seen that could confirm the COVID-19 diagnosis. (Figure 1)
At this time, there was no evidence of COVID-19 so he got serum injections and pantoprazole (40 mg BD)for his abdominal pain. But 12 hours after admission, the patient’s oxygen saturation at ambient air decreased to 79% and he developed dyspnea, requiring admission to the intensive care unit (ICU) to increase the oxygen saturation. At this time, the patient’s general condition was not good enough for performing CT-Scan but in portable sonography a thickening of the gallbladder wall, low volume free liquid in pelvis interlope space and hepatitis was seen. After improvements in patient’s general condition a chest X-Ray was done and patch like lesions was seen from the apex to the base of both lungs. The administrated ICU treatment combined oxygen therapy with low-flow oxygen therapy with reservoir bag and corticosteroid therapy with dexamethasone (4mg stat and BID) and remdesivir (200mg stat and 100 mg daily) was given as the COVID-19 pandemic was happening at the moment. Another treatment that was given was ceftriaxone which was injected intravenously (1G, BID) because of the probability of leptospirosis which is a tropical infection that at the time was endemic in northern areas of Iran and also the patient mentioning attempting to paddy increasing the possibility of this infection. Leptospirosis could be the reason of his pulmonary symptoms that can happen when multi-organ failure happens by this infection so that hemorrhagic lesions in lungs at chest X-Ray can be the presence of this infection in lungs.
But after some hours, because of the slow increase in oxygen saturation at ambient air, because of the possibility of cytokine storm, Baricitinib (4 mg daily) was given orally.
On day 3 of admission, Procalcitonin was high at 4.14 ng/mL which shows sepsis or viral is likely that has affected kidney and a high N-terminal pro b-type Natriuretic peptide (NT- proBNP) at 9641 pg/ml can be because of the myocarditis caused by Covid-19 or leptospirosis infection, so Furosemide was injected intravenously (40 mg BD).
At this stage, Leptospirosis serology was performed on day 6 with ELISA (OneSiteTM Leptospira IgM/IgG Combo Rapid Test) and reported the presence of anti-Leptospira IgMs at 5.8 NTU*(Negative result<9 NTU) and IgGs at 4.6 NTU (Negative result<9 NTU).
After getting treatments mentioned above, the patient started to get better and was discharged after 10 days of hospitalization.