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An Atypical Presentation of Novel Coronavirus Disease 2019 (COVID-19)

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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.

She was brought in again 3 days later with altered mental status. She had no fever, chills, chest pain, cough or shortness of breath. Family denied sick contacts or recent travel. Blood pressure was 100/51 mmHg, pulse 94 beats/minute, respiratory rate 22/minute, temperature 98.0°F and oxygen saturation 96% on 2 L oxygen. She was lethargic. She had minimal crackles bilaterally. Laboratory indices showed normal electrolytes, white blood cell count 4300/mm3 (absolute lymphocyte count 1.0 K/mm3). Pro-calcitonin was normal. Head CT was negative. CT angiography of the head and neck showed groundglass attenuation in the left upper lobe. This triggered us to order chest CT which showed bilateral groundglass densities extending from the hilum to the left upper lobe and middle lobe (Figure 1A, 1B). We suspected Coronavirus disease 2019 (COVID-19) and patient was immediately placed on isolation. Pulmonary and infectious disease were consulted, and broad-spectrum antibiotics were initiated. Novel COVID-19 polymerase chain reaction (PCR) was sent and came back positive.

Figure 1

Figure 1A, B, Computed tomography of chest showing groundglass densities present bilaterally, extending from the hilum, more prominent toward the periphery in the left upper lobe and middle lobe.

Coronaviruses are RNA viruses where genetic recombination can result in increased diversity leading to emergence as novel pathogens. Their viral spike (S) binds to host angiotensin-converting enzyme 2. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is identified in disease COVID-19. It spreads via respiratory droplets between close contacts, defined as within 6 feet of the person and at least 15 minutes of time spent in proximity. The virus may remain infectious in aerosols for hours, and on surfaces up to days. Infection may be asymptomatic or may result in an acute respiratory disease with fever, shortness of breath and cough. Bilateral pneumonia, acute respiratory distress syndrome, or death can occur.

Clinical Characteristics of Coronavirus Disease 2019 in China.