Scenario 2: an 83 year old elderly man presented to our hospital with low grade fever and productive cough of one-week duration and shortness of breath of 3 days duration. He also reported an episode of streaky hemoptysis and a background history of treatment for a sputum-confirmed pulmonary tuberculosis, 19 years previously. There was a recent history of a self-limiting sore throat and generalized body weakness. He was hypertensive and diabetic but reported good drug compliance. He had presented at the early stage of community transmission of COVID-19 infection within the country with strong consideration given to its likelihood. However, he had been screened for COVID-19 through RT-PCR test from nasopharyngeal and throat swabs obtained at an accredited outside laboratory which returned negative; the result of which he made available at the time of admission to our facility. The remarkable findings on clinical examination were tachypnoea (respiratory rate of 36/minute), poor room air oxygen saturation of 90%, tachycardia (pulse rate of 100/minute) and systemic hypertension (blood pressure of 165/96mmHg). All initial laboratory blood panels were within normal limits except for borderline elevation in serum creatinine of 1.6mg/ml (normal: <1.5mg/dl) and low estimated glomerular filtration rate of 45.5ml/min/1.73m2 (normal: >90ml/min/1.73m2) indicating low renal reserve.
The chest radiograph done on admission revealed dextrocardia with features of multiple consolidations in both lung fields demonstrating peripheral disposition. There was no evidence of pleural or pericardial effusion (Figure 5). A 12-lead electrocardiogram revealed features of left ventricular hypertrophy and left axis deviation with sinus tachycardia. Two-dimensional trans-thoracic echocardiography revealed concentric left ventricular hypertrophy with good biventricular systolic function (left ventricular ejection fraction {EF} of 65% and Tricuspid Annular Plane Systolic Excursion {TAPSE} of 2.5cm).
Given the negative COVID-19 test, the clinical diagnosis of community-acquired bacterial pneumonia was made with a differential diagnosis of reactivated pulmonary tuberculosis. He was commenced on broad-spectrum antibiotic therapy according to hospital infectious disease protocol for community-acquired pneumonia as well as other supportive therapy, including corticosteroids and anticoagulants. Consideration was also given to commencement of a trial of empirical anti-tuberculous therapy because of his past medical history. However, his clinical condition remained poor, necessitating further imaging evaluation with chest computed tomographic (CT) scan on the 5th day of admission (12th day from the onset of illness) which revealed diffuse ill-defined ground glass densities in both lungs with multiple peripherally-distributed non-enhancing peri-bronchovascular consolidations especially in the lower lobes. There was bilateral pleural thickening with mild cardiomegaly (CTR=54%), rightward cardiac apex, and bovine branching pattern of a rightward aortic arch consistent with dextrocardia. The liver was located on the left and the spleen on the right, in keeping with a situs inversus (Figure 6). These imaging findings heightened suspicion of COVID-19 viral pneumonia, especially as there was a prevailing surge in community-transmitted cases at the time. The patient was transferred to the hospital isolation facility with repeat throat and nasal swabs sent for the COVID-19 test, which returned positive after five days. The patient made a full recovery from the infection and was discharged home after 16 days in the isolation centre after two subsequent consecutive COVID-19 RT-PCR tests had returned negative. No hospital staff among the primary contacts of this patient was reported to be infected with COVID-19 after contact tracing and isolation.