We report the case of a 76-year-old woman, BMI= 30, with hypertension and diabetes mellitus who presented to the emergency department with abdominal pain and shortness of breath, she also reported fever and non-productive cough 5 days before. Physical examination at admission in the ICU revealed blood pressure of 160/90 mmHg, heart rate of 110 beats per minute, oxygen saturation of 89% while breathing ambient air, and body temperature of 36.8 C, capillary blood glucose was superior to 5g/L, and dipstick showed high levels of ketones. The arterial gas analysis showed pH 7.31, PCO2 39.4 mmHg, PO2 68 mmHg, HCO3= 18 mmol/L. The patient s diabetic ketoacidosis was resolved after insulinotherapy and symptomatic treatment and the evolution was the apparition of severe hypoxia and ARDS requiring orotracheal intubation with mechanical ventilation (Volume assist-control ventilation 6 mL/kg, PEEP= 10 mmHG, FiO2= 80%). Based on the patients  clinical evolution and the COVID-19 outbreak, a viral pneumonia of SARS-COV-2 was deemed as likely. The thoracic CT scan showed bilateral extended alveolar interstitial infiltrates exceeding 75% in the left lung (Figure 1), PCR of nasopharyngeal swab was performed with a positive result for SARS-CoV-2. Blood tests were in favor of COVID-19 with Lymphopenia and Hyperferritinemia, elevated C-reactive protein and normal procalcitonin. High sensitive troponin I and Brain natriuretic peptide (BNP) levels were normal.
The findings on the 12-lead electrocardiogram (ECG) were unremarkable and transthoracic echocardiography (TTE) showed an aspect of hypertensive cardiomyopathy with an estimated LV ejection fraction (LVEF) of 55%. LV diastolic function was mildly impaired. Right ventricular dimensions and function were normal. We noted a small pericardial effusion most notable around the right atrium (maximum 7mm). Thus, a therapy according to the Moroccan treatment protocol with Hydroxychloroquine and azithromycin was initiated. On the 10th day of onset, the patient presented fever with a temperature of 39.4 C (103 F), and hypotension (84/46 mmHg) requiring vasoactive support (norepinephrin). Blood sample tests showed higher level or High C-reactive protein (432 mg/L) and an important increase in procalcitonin (2,32 ng/mL). Both blood cultures and cultures performed in the patient s jugular catheter were positive for Coagulase-negative staphylococcus. Cytobacteriological examination of urine showed presence of Candida tropicalis. The patients also presented a biological disseminated intravascular coagulation.
The TTE was performed (Figure 2) and this time revealed in addition to the first findings a large, oscillating vegetation measuring 15 x 10mm attached to the anterior tricuspid valve leaflet chordate associated with a moderate tricuspid with an estimated pulmonary artery pressure of 35 mmHg. However, no right chambers  dilatation or right ventricular dysfunction were noted. The diagnosis of tricuspid valve infective endocarditis was thus established accordingly to the modified Duke criteria and antibiotherapy with vancomicyn 30 mg/Kg/day and rifampicin 900mg/day was started. We also added voriconazol 200mg/day for the candida tropicalis. The evolution was good with progressive apyrexia and stabilization of blood pressure, norepinephrin was weaned on the 5th day. On the 21st day, tracheostomy was performed and mechanical ventilation weaning was carried out successfully using a daily T-tube. Control TEE revealed a reduction of the vegetation size (Figure 3), and therefore, surgery was not considered. At the time of submission, the patient was hospitalized with progressive clinical and hemodynamic improvement.
Thoracic CT scan showing bilateral extended alveolar interstitial infiltrates exceeding 75% in the left side in favor of COVID-19.