1st case
S.D., an 87-year old Indian lady (SD) experienced sudden onset of fever, cough, diarrhea, anorexia, profound weakness and slight shortness of breath, 10 days following a 2-hour flight from New Delhi to Indore, Madhya Pradesh, India. Patient had received the first dose of COVISHIELD vaccine 30 days prior to beginning of symptoms. Patient was examined by the first author. Patient was fully alert, oriented and able to make intelligent conversation but lay listlessly in bed unable to ambulate. Patient weighed 42 Kg and exhibited severe muscle wasting and marked kyphosis. Vital signs revealed temperature, 102o Fahrenheit; heart rate, 100 per minute; blood pressure, 90/60 mm of Hg; and respiratory rate, 22 per minute. Mucosa were moist and mild pallor was present. There was no jugular venous distention or pedal edema. Chest examination revealed bilateral coarse rales especially prominent at both lung bases but no wheezes. Abdomen, cardiovascular and neurological examinations were unremarkable. Patient was not taking any medications.
Past medical history included hypertension for over 40 years; Hashimoto’s thyroiditis with thyrotoxicosis for over 30 years treated with radioiodine therapy in 1999; severe osteoporosis with kyphosis; coronary artery disease leading to acute myocardial infarction and cardiac arrest in 2015 which required emergency coronary angioplasty and stent placement; chronic kidney disease with estimated glomerular filtration rate of about 20 mL/min.
Nasopharyngeal and oropharyngeal swabs were positive for SARS-CoV-2 infection by RNA PCR with cycle threshold (Ct range < 20 cycles). Pulse oximetry revealed oxygen saturation of about 85–88%. Patient was admitted on April 9, 2021 to Medanta Hospital, Indore, Madhya Pradesh, India. CT scan revealed moderate multifocal, patchy ground glass opacities, and consolidation. There was septal thickening in the central and peripheral subpleural aspect of both lung parenchyma. Serial laboratory examinations during the course of the illness are listed in Table 1.
During the hospital stay the patient was treated with intravenous remdesivir, antibiotics and methylprednisolone. In addition, prophylactic low-molecular weight heparin was administered subcutaneously in a dose of 40 mg twice a day. Patient required high-flow nasal oxygen during the hospital stay. Patient continued to have fever, cough, shortness of breath, diarrhea and profound weakness during the hospital stay. Oxygen saturation on room air ranged between 82–86%. After a hospital stay of 5 days the patient was discharged upon her request on April 14, 2021. Discharge medications included oral oseltamivir, doxycycline, vitamin C, aspirin 75 mg once a day, 5 mg prednisolone, vitamin D3, and nebulization with budesonide and salbutamol twice daily. Supportive management with betadine gargles, steam inhalation and breathing exercises was continued.
On April 15, the day after discharge from the hospital, the patient had fever with a temperature of 101o Fahrenheit. Pulse oximetry revealed an oxygen saturation of 82–84%. Patient was profoundly weak and unable to get out of bed without assistance. At this time all drugs including low-dose aspirin were discontinued and the patient was started on ramatroban in a dose of 75 mg tablet, one-half tablet (37.5 mg) twice daily. Within 36 hours, after having received three doses of ramatroban, patient’s oxygen saturation improved to 90% on room air and there was progressive improvement in her general condition. The dose of ramatroban was increased to 37.5 mg in the morning and 75 mg at bedtime. Patient had complete resolution of cough and diarrhea over a period of next 3 days, and started ambulating independently without assistance. Patient had recovered almost completely by April 22, 2021.
Table 1
| Analytes | Before admission April 8, 2021 | During hospital stay April 13, 2021 | After discharge April 16, 2021 | Reference Value |
| Hemoglobin (g/dl) | 11.7 | 12.1 | 12.0 | 13.0–17.0 |
| Platelet count (per mm3) | 214,000 | 285,000 | 402,000 | 150,000-410,000 |
| RBC count (x 102/L) | 3.77 | 3.93 | 4.01 | 4.5–5.5 |
| WBC count (per mm3) | 5040 | 12100 | 9010 | 4000–10000 |
| Neutrophils (%) | 77 | 80 | 86 | 38–70 |
| Lymphocytes (%) | 18 | 11 | 07 | 21–49 |
| NLR (Neutrophil:Lymphocyte Ratio) | 4.3 | 7.3 | 12.3 | 1.1–3.5 |
| Serum CRP (mg/L) | 7.86 | 35.9 | 15.3 | 0–5.0 |
| D-dimer (ng FEU/mL) | 600 | 650 | 659 | < 500 |
2nd case
A 31-year old businessman at New Delhi experienced sudden onset of fever, cough and dyspnea. The nasopharyngeal and oropharyngeal swabs were positive for SARS-CoV-2 infection by RNA PCR. Pulse oximetry revealed an oxygen saturation of 80–82%. Patient was started on ramatroban 75 mg twice daily. Within 36 hours the patient experienced remarkable improvement in symptoms and oxygen saturation improved to 90–95%. Patient did not require admission to the hospital.
These case reports are retrospective descriptions of two patients, their laboratory profile and clinical course. Consent or waiver of such consent was deemed unnecessary and unwarranted considering the patients have not been identified in the case report.