A previously healthy 53-year-old Hispanic male presented to the Emergency Department with a cough and non-massive hemoptysis. The patient had recently been diagnosed with COVID-19 one month prior and did not require hospitalization. The patient reported recovery but had a recurrent cough, hemoptysis, and centralized chest pain that started two weeks prior with a progressively worsening cough. Fatigue, generalized muscle pain, and loss of appetite were also noted. The patient denied fever, shortness of breath, nausea, vomiting, and/or diarrhea at the time of presentation. The patient denied any history of prior kidney disease, diabetes mellitus, exposure to Tuberculosis, history of drug abuse, tobacco, and alcohol intake. On physical examination, the patient was tachycardic without signs of acute distress, the physical exam was unremarkable. Initial laboratory results are shown in Table 1.
An electrocardiogram showed sinus tachycardia with no ST elevations or depressions. Initial Chest X-Ray revealed bilaterally scattered infiltrates that were denser with partial consolidation in the right upper lobe bordering the minor fissure (Fig. 1).
CT of the chest with no contrast showed multiple patchy consolidations throughout both lungs of which some are cavitating and are located primarily at the periphery (Fig. 2).
Findings were likely suggestive of multifocal pneumonia.
The patient's blood, urine, and sputum cultures were taken. Urine analysis, protein/creatinine ratio, FeNa, urine osmolality, and SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) were ordered. Additionally, hepatitis and human immunodeficiency (HIV) panels were ordered. The patient received antibiotic therapy targeting community-acquired pneumonia with Azithromycin 500 mg IV and Ceftriaxone 2g IV, and Sodium bicarbonate drip at 125 cc/hr and emergent hemodialysis per nephrology recommendation. Pulmonology was also consulted on admission.
Infectious workup results in the setting of acute kidney injury with pulmonary-renal disease are shown in Table 2.
Additional inflammatory and autoimmune workup revealed; CRP >200 mg/L, D-Dimer 6.41 mg/L, Fibrinogen 561 mg/dL, LDH 367 U/L, TSH 5.425, T3 1.55, T4 0.77, A1c 6.5. The patient was started on levothyroxine for newly diagnosed hypothyroidism and sliding scale insulin for newly diagnosed diabetes mellitus type 2. Notably, the patient had decreased complement C3 and C4 levels, negative Anti-Glomerular Basement Membrane antibody, negative Anti-streptolysin O antibody, positive Rheumatoid Factor, positive ANCA assay, positive Proteinase antibody, mildly positive Myeloperoxidase antibody, and positive Cytoplasmic C-ANCA (Table 3).
Despite hemodialysis, the patient experienced worsening AKI, ongoing hemoptysis containing clots with hypoxemia necessitating increased FiO2 requirement to 50%, with development of new onset nonpruritic petechiae that began on hospital day#3 in the bilateral lower extremities. The petechiae were associated with tenderness on the plantar surface of the foot in the calcaneal region with concomitant platelet drop from 226 to 187 (Fig. 3).
The patient continued to develop petechial lesions in the acral regions, specifically bilateral hands, and his nose (Fig. 4).
Previously petechial lesions on the bilateral lower extremities progressed to palpable purpura (Fig. 5).
The patient was started on an IV pulse dose of Methylprednisolone therapy 125mg every 6 hours and was also scheduled for a renal biopsy to obtain a definitive diagnosis, but this was delayed due to the increased international normalized ratio. During hemodialysis on day#5, the patient experienced increasing shortness of breath and tachycardia which prompted Computed Tomography Angiography of the chest that revealed markedly increased pulmonary infiltrates. Due to increasing respiratory distress and impending respiratory failure, the decision was made to intubate the patient, upon which active frank red bleeding arising from the trachea was noted. Shortly after intubation, the patient continued to have what looked like diffuse alveolar hemorrhage and sustained 2 consecutive PEA cardiac arrests; unfortunately, the patient expired.
Community-Acquired Pneumonia with post-inflammatory lung changes due to COVID-19
Pulmonary Mycobacterium Tuberculosis Infection
Goodpasture's disease
Invasive Fungal disease (Aspergillosis/Coccidioidomycosis)
ANCA-associated Vasculitis
Computed Tomography Chest. CT Chest shows multiple patchy consolidations throughout both lungs, some of which are cavitating and are located primarily at the periphery.