2.1 Case introduction
An 80-year-old male was admitted to our hospital on 1 January 2023 with complaints of "fever, cough, sputum and vomiting for more than 10 days". On 22 December 2022, the patient started to have a fever with a maximum temperature of 39 degrees. It was accompanied by discomfort such as sore throat, cough, dyspnea and vomiting, and the vomit was stomach contents. Tests for IgG and IgM antibodies specific for COVID-19 were positive. This patient had a previous history of type 2 diabetes mellitus, hypertension and coronary atherosclerotic heart disease for many years.
2.2 Physical examination of admission
On admission, a physical examination was performed on the patient. The patient had temperature of 36.5℃, pulse of 73 times per minute, respiratory rate of 20 breaths per minute, blood pressure of 155/76mmHg, finger pulse oxygen saturation of 86% and fingertip random blood glucose of 3.8 mmol/L. Breath sounds were coarse in both lungs. And wet rales could be heard in both lungs.
2.3 Accessory examination
Complete Blood Count(CBC) showed leukocytosis of 7.01G/L, lymphocyte of 0.98G/L, ESR-T of 91mm/h, PCT-F<0.05 .Blood gas analysis showed PH was 7.39, PCO2 was 5.07Kpa, PO2 was 8.26Kpa and SPO2 was 91.9%. CRP was high(82.72mg/L). Chest CT showed multiple patchy, nodular and small patchy shadows of increased density in both lungs, as well as partial ground glass lesions. This suggested viral pneumonia.
2.4 Treatment and clinical manifestations
From January 1 to January 9, the patient's temperature was normal. He was conscious, with mild wheeze and cough. His heart rate fluctuated from 60 to 88 beats per minute and respiration from 18 to 23 breaths per minute. Cefoperazone sulbactam sodium was given as an antibacterial agent and methylprednisolone as an anti-inflammatory agent. Anti-spasmodic and anti-asthmatic treatment and nebulized inhalation was also given, supplemented by sputumification and oxygen care (3L/min). The patient's symptoms improved during this period. On the night of January 9, the patient complained of throat discomfort and sore throat, and the symptoms were slightly improved after receiving Jinhoujian spray. Sputum culture showed both Gram-positive and Gram-negative bacteria. A fever developed on 10 January, with maximum temperature of 37.8℃. At night he complained of pharyngeal discomfort and dysphagia. Nebulisation was given but there was no significant relief of symptoms.
At 6am on 11 January, the patient suddenly developed shortness of breath and his oxygen saturation dropped to 70-81%. He presented with inspiratory dyspnea and the three concave sign was obvious. An emergency tracheotomy was immediately performed by Anesthesia Department. Obvious redness and swelling of the throat tissue were seen at the time of intubation. After intubation, the blood oxygen level recovered to 94%-95%. Hormone anti-inflammatory and meropenem anti-infective treatment were continued.
His condition improved (Table 1.) and was discharged 16 days after receiving the tracheotomy.
Table 1 Laboratory test result from day 1 to day 13
Test Item
|
1.1
|
1.9
|
1.11
|
1.12
|
1.13
|
HSCRP
|
82.72↑
|
37.42↑
|
142.03↑
|
118.33↑
|
38.9↑
|
WBC
|
7.01↑
|
13.36↑
|
20.71↑
|
22.69↑
|
11.96↑
|
NEUT#
|
4.89
|
11.08↑
|
18.06↑
|
20.67↑
|
9.93↑
|
NEUT
|
69.7
|
82.9↑
|
87.2↑
|
91.1↑
|
83↑
|
PCT-F
|
<0.05
|
<0.05
|
0.39↑
|
0.42↑
|
-
|