COVID-19, Yes or Not? No definitive answer

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In March 2020 the COVID-19 pandemic was hitting hard in Spain.  In this period we were  attending  patients in the medical oncology ward, some of them with respiratory insufficiency, usually associated with the tumor or their complications, but there were

also  a group of patients with abnormal pulmonary images highly suspicious of a SARS-CoV-2 infection. The truth is that, just by chance or because we practice more tests, we found a cluster of clinical cases and images without a definitive diagnosis or explanation, what it is not uncommon in Medicine.

Clinical case

A 69-year-old man had a diagnosis of pancreatic cancer and diabetes .  After five days of the last dose of chemotherapy, he  went to the hospital with mild fever, and  shortness of breath,

His blood test showed a renal insufficiency with creatinine levels five times the normal value and a metabolic ketoacidosis.

We show here the first X-ray

Clinical follow up

He was initially neutropenic after chemotherapy and he was treated with broad spectrum antibiotics (meropenem, linezolid and claritromicin). He tested negative for Legionella and Pneumococcus antigens in the urine. He also tested negative for Influenza type A and respiratory syncytial viruses. Blood samples were negative. The fecal Clostridium difficile toxin A and B was positive.

The basal oxygen saturation was 89%, but improves  with oxygen. The Lactic dehydrogenase was normal, and he was not receiving steroids in a long term.

Physical examination: he was with a hard respiratory work while resting. His lung examination showed a mix of roncus and crackles.

PCR (Polimerase Chain Reaction) determination for SARS-CoV-2 was negative in three samples.

Evolution

After a week of treatment, an improvement in the general condition was observed. We kept the antibiotics for two weeks, and the lung function improved day by day.

Final evolution

He went back home with a clear improvement in his general situation and his respiratory function.

Six weeks after the first consultation, the patient has been tested negative for Immunoglobulin M and G associated with the SARS-CoV-2 virus.

We show here the last X-ray and the CT

 

 

 

 

 

 

 

 

Final Comments

Different clinical entities  share similar radiographic patterns. The radiographic aspect of the new COVID-19 disease has been established, but the question is that many other pathological entities must be included in the differential diagnosis. During the pandemic period, between March and  May, we have seen patients with a clinical picture highly compatible with  COVID-19, but with a  PCR-test for SARS-CoV-2  negative, a situation that could be associated with a false negative test or another clinical entity with a very similar radiographic pattern to COVID-19.

ADDENDUM

We show here  a second patient with a diagnosis of non-Hodgkin Lymphoma, with a quick deterioration during the same period, but with PCR test negative for coronavirus, without a good response to antibiotics, trimethoprim sulfamethoxazol or antifungal therapy.

First X-ray: shortness of breath, PCR for SARS-CoV-2 negative
A week later: PCR for SARS-CoV-2, negative
Ten days from the first image: shortness of breath, deterioration. No response to Trimethoprim sulfamethoxazol and steroids. A new PCR tes (the third one) for SARS-CoV-2 negative.
CT scan the same day that previous X-ray

 

Have you had a similar experience?

Author: Lorenzo Alonso

FORO OSLER

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