To the Editor
A 71-year-old female with hypertension came to emergency department (ED) with complaints of syncope. She did not have chest pain, shortness of breath, fever or cough. Blood pressure was 152/70 mmHg, 139/75 mmHg and 128/75 mmHg at supine, sitting and standing position respectively. Temperature was 98.5°F, pulse 114 beats/minute, respiratory rate 18/minute and oxygen saturation 96% on room air. She was awake, alert and had clear lungs. Electrocardiogram showed normal sinus rhythm. Glucose was 143 mg/dL, sodium 136 mmol/L, potassium 4.0 mmol/L, creatinine 1.34 mg/dL (normal baseline) and normal Troponin. White blood cell (WBC) count was 4100/mm3 with absolute lymphocyte count 0.64 K/mm3 (normal 0.80 – 5.00 K/mm3). Computed tomography (CT) of the head was negative. Chest radiograph showed calcified granuloma in the right upper lobe and clear lungs. She was diagnosed with orthostatic hypotension and was given intravenous fluids and was sent home from the emergency department.
Some patients have experienced gastrointestinal symptoms such as diarrhea and nausea. Hypertension, heart disease, and chronic lung disease are risk factors for severe disease.
Median incubation period is 5.1 -5.2 days. Asymptomatic phases range from 2 to 14 days. 97.5% of patients develop symptoms within 11.5 days (CI, 8.2 to 15.6 days).
Negative procalcitonin and groundglass densities in chest CT favors COVID-19.
Management includes prompt implementation of infection control and supportive management for respiratory disease and complications like septic shock or acute respiratory failure.
Role of non-invasive ventilation is limited and in fact harmful. Corticosteroids should be avoided because of the potential for prolonging viral replication. Drugs like Remdesivir and Chloroquine have potential benefit, but their safety and efficacy is unknown.
Negative procalcitonin, presence of lymphopenia and chest imaging made us suspect COVID-19 in our patient as she did not have any classic symptoms of fever and cough. Due to this ongoing highly contagious disease, we would like to inform the providers that altered mental status in an elderly patient can be an atypical presentation of COVID-19.
Clinical Characteristics of Coronavirus Disease 2019 in China.
N Engl J Med. February 2020; ()https://doi.org/10.1056/NEJMoa2002032
In Press Journal Pre-Proof
Funding source: None
Conflict of interest: Authors do not have any conflict of interest to disclose.
Author contributions: All authors had access to the data and a role in writing the manuscript.
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