On the 14th of March 2020, a 36-year-old gentleman presented at the emergency unit of a nearby hospital with fever, dry cough, head and limb aches that started three days earlier. In good physical condition and otherwise healthy, he had completed a half-marathon the week before, but on admission to another hospital, he presented with reduced general condition and shortness of breath. Physical examination revealed crackles in the right upper lobe upon auscultation. Medical, family, and psychosocial history was completely unremarkable.
As SARS-CoV-2 was suspected, he was immediately admitted to the ICU. He received microbiological and virological sampling as well as chest X-ray and thoracic CT. A calculated antimicrobial chemotherapy with piperacillin/tazobactam (3 x 4.5 g/d i.v.) and clarithromycin (2 x 500 mg/d i.v.) was started. Polymerase chain reaction (PCR) for SARS-CoV-2 was negative, as were the results for influenza, Mycobacterium tuberculosis, and Legionella spp. After 2 days, the antimicrobial regimen was changed to meropenem (3 x 1.0 g/d i.v. ), linezolid (2 x 600 mg/d i.v.) and fosfomycin (3 g/d i.v.) due to persistently elevated inflammatory parameters and further clinical deterioration. However, the assumption of the patient having COVID-19 was maintained. Imaging of the lungs revealed a diffuse interstitial reticular pattern, multilobular patchy ground-glass opacification and consolidation of the right upper lobe.
After a week on high-flow oxygen, he deteriorated and was intubated. Despite proning, he deteriorated further, needing higher doses of vasopressors (0.2 µg/kg/min), and our hospital’s extracorporeal membrane oxygenation (ECMO) team was called on the 22nd of March 2020 to transfer the patient. The patient was reported as having COVID-19 and moderate CARDS with respiratory acidosis.
The ECMO team set out to transfer the patient under COVID-19 personal protective equipment (PPE). In the external hospital, after reviewing the laboratory and imaging findings, as well as the ventilator settings, the team leader decided against implanting an ECMO on site, and the patient was transferred under COVID-19 precautionary measures. After an otherwise unremarkable transport, the patient had to be re-intubated, as the cuff was leaking. On that occasion, bronchoscopy with bronchoalveolar lavage (BAL) was performed for microbiological sampling and to further elucidate the hypothesis of an infection with SARS-CoV-2. Additionally, a naso- and oropharyngeal swab for SARS-CoV-2 was obtained.
As the lung’s compliance was preserved, we accepted a Pinsp of 30 cmH2O at a PEEP of 10 cmH2O, with a respiratory rate of 22/min. The patient was slightly hypercapnic at a pH of 7.39. The oxygenation index on admission at our unit was 115.
Chest radiographs were reviewed, and a new chest X-ray was made (Figure 1). Imaging showed mainly right-sided pneumonia, not typical for COVID-19, and the hypothesis of COVID-19 was abandoned. Antimicrobial therapy was changed, as atypical pneumonia was suspected. Meropenem (then given continuously i.v., monitored by determination of serum levels) was continued for a total of 7 days, and clarithromycin (2 x 500 mg/d) was added to the antimicrobial regime again (Table 1). Remarkably, for a young and otherwise healthy individual, the patient had elevated bilirubin and LDH levels, with diminished haptoglobin and macrocytic hyperregenerative anemia (hemoglobin 5.3 g/dL at a scvO2 of 67%) on admission, demonstrating hemolysis. Coombs’ test revealed cold agglutinins the same day.
Microbiological results from a BAL on the 22nd of March were negative for SARS-CoV-2, Pneumocystis jirovecii, Bordetella pertussis and B. parapertussis, Chlamydophila pneumoniae, Haemophilus influenzae, Legionella pneumophila, Moraxella catarrhalis and Streptococcus pneumoniae; however, the patient tested positive for Mycoplasma (M.) pneumoniae. Thus, a diagnosis of mycoplasma-related ARDS with cold agglutinin disease was made. The patient was in total substituted with 4 units of packed red blood cells and received only warm infusions using a Level One infusion system (Smiths Medical, Minneapolis, Minnesota, USA). Ventilator support was deescalated soon after change of the antimicrobial regimen, and the patient was extubated on the 25th of March and received noninvasive ventilator support for 4 days. Meropenem (then given continuously i.v., monitored by determination of serum levels) was continued for a total of 7 days, and clarithromycin (2 x 500 mg/d) was added to the antimicrobial regime again (Table 1). Hemolysis improved quickly under the antibiotic regime. The patient was discharged from the ICU on March 30 and was discharged home on April 6. He had no health-related complaints in a telephone interview conducted on June 18th.