COVID-19 or NOT?

A 75-year old man with a history of hypertension, hemorrhagic cerebral infarction one year before, right-sided hemiparesis, and atrial fibrillation was brought to my hospital because of suspicious COVID-19 infection. He was seen in the ER because of a few days of dyspnea which became progressed and bad clinical condition. 7 days before the current presentation patient fell from its bed, and after that, he started to feel pain in his right part of the chest. He also noticed purple discoloration of his feet and left hand, which was painful and progressed further during the next days. He started to have DYSPNOEA, which also progressed. CBC: showed leukocytosis (26,9) and chest X-ray was described as bilateral pneumonia. On exam, the patient was alert, disoriented in time, immobile on the bed, with an obvious right hemiparesis, afebrile, tachypneic (R: 24/min), and bradycardic (P: 55/min), hypoxic (SpO2: 80%), with normal blood pressure. PHYSICAL EXAMINATION: showed dusky purple discoloration of both feet and fingers of the left hand. The patient's right feet showed some darker areas, which could be hematomas. CHEST EXAMINATION: showed the painful right side & we spotted the fracture of the 7th rib. Auscultation of lungs revealed bilateral inspiratory crackles, predominantly on the right side. The heart rhythm was regularly-regular. The rest of the examination was unremarkable. LAB ANALYSIS: revealed elevated urea (11,1) and creatinine (371), hypoalbuminemia (22), elevated LDH (705), and slightly elevated CK (201). The CRP was elevated (272,5), and coagulation panel was highly abnormal - aPTT 85,1s, PT 15%, INR >6,0, fibrinogen 2,4, and D-dimer 162 (normal <0,5). My (differential) diagnosis list for this patient was: - Fat embolism - Warfarin overdose - Bilateral pneumonia - Sepsis He didn't have any criteria for COVID-19, and also, its clinical presentation and disease course was not consistent with COVID-19 infection. The patient was transferred to ICU for further treatment. What do you say on this? I am mostly inclined to fat embolism in the first place, which was complicated, but I do not have experience with this diagnosis. What is your opinion on this case, what would be your further diagnostics and treatment?

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Hemiplegic pt with multiple comorbidies on anticoagulants Xray chest do shows GGO bilateral suggestive of pneumonitis There is #ribs Leucocytosis suggest septicemia All probabilities septicemia causing thromboembolic phenomenon with consequent complications Unlikely covid19

Thanx dr Ashok Leel
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A nicely presented case . Your D/D is justified in fat embolism, warfarin overdose, bilateral pneumonia, sepsis, Another addition in D/D could be PULMONARY EMBOLISM Points in favour of pulmonary embolism are 1.Atrial fibrillation 2.Dyspnoea and SPO2- 80 % 3.There may be associated DVT in this case . 4 patient in uraemia,. 5.D - Dimer 162 - significantly raised goes in favour of pulmonary embolism. A CT pulmonary angiography is needed to confirm the Diagnosis.

Agree. Pulmonary embolism to be ruled out
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No stigmata to suggest COVID 19. Blood picture is in favour of septicemia.How much is the BP. Is he in septic shock. No leukopenia or lymphopenia to suggest COVID.Leg picture is suggestive of ischemia both feet left more than rt.There is no long bone fracture to suggest fat embolism.Coagulation factors abnormal with high CRP with significantly deranged RFT, all pointing to septicemia probably with septic shock. elevated INR probably due to warf induced. Needs cardiac evaluation Nephrology opinion broad spectrum antibiotics with FFP. INR is high ,well anticoagulated and unlikly to get AF induced ischemic lesion.Still septic embolism is possible. Septicemia with multi organ involvement can explain most of the lesions including lung lesion

Very nice case presentation Though in today's scenario every critical patient need to be considered as COVID 19 unless proved otherwise COVID 19 need to be kept as top differential diagnosis This patient has few factor which goes against diagnosis of COVID 19 1) No history of fever 2) Leukocytosis - COVID 19 typically has normal WBC count 3) Multiple comorbidities suggest possibilities of many other differential diagnosis - such as warfarin causing raised INR, pneumonia etc

COVID 19 tests must be considered. Investigation and evaluation to conclude as per your DD . Fat embolism and pneumonia Needs regular evaluation and constant monitoring required because pt is suffering from multiple comorbidities your inclination is may be more suited to the condition of the pt.

Thanks Dr Pushkar Bhomia
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A case of ITP DD sepsis with DIC.as scenario going on test throat swab for RT_pcr for covid 19.CVA might be due to thromboembolism

Sepsis followed by DIC and fat embolism duo to rib fracture Leads to septic shock Cardiac ishchemia with carcinogenic shock

This is septicaemia with bilateral pneumonia. DD:- atypical pneumonia’s- Legionerre’s or Swine- flue( Influenza).

Purpura both feet with Echymotic patches Nails cynosed Most likely warfarin over does leading to DIC

Please rule out covid-19... I don't think it is anyway...I would like to stick with your DDs..

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