A 62-year-old woman with no known past medical history presented on February 23, 2020, with sudden onset shortness of breath at rest for one week associated with hemoptysis. On interrogation, she referred intermittent yellow sclera for one month, and her son mentioned heavy alcohol consumption. She migrated from Mexico more than 30 years ago and was never in contact with a known tuberculosis case. Given her illegal alien immigrant status, she had limited access to health care and had no regular follow-ups with primary care physicians.
On presentation in the emergency department, she was tachypneic and tachycardiac with significant respiratory distress. She was placed on a nonrebreather mask, started on broad-spectrum antibiotic therapy as per sepsis protocol, and transferred to a progressive care unit (PCU). In the PCU, she was further upgraded to bilevel positive airway pressure. Her exam was significant for scleral icterus and dried blood on lips and chin, diffuse crackles over bilateral lower lung fields, and bilateral lower extremity pitting edema.
Initial lab results showed a white blood cell count of 25.7 k/mm3 (4.0-11.0 k/mm3), hemoglobin of 10.1 g/dL (12.0-15.3 g/dL), and platelet count of 71,000 k/mm3 (150-450 k/mm3). Other lab values of note included albumin of 2.9 g/dL (3.5-5.7 g/dL), alkaline phosphatase 172 IU/L (35-104 IU/L), aspartate aminotransferase (AST) 133 IU/L (13-39 IU/L), alanine aminotransferase (ALT) 32 IU/L (7.0-52.0 IU/L), bilirubin 12.4 mg/dL (0.0-1.0 mg/dL), lactate 2.2 mmol/L (0.7-2.0 mmol/L), BNP 886 pg/mL (0.0-100 pg/mL), high-sensitivity troponin 449 pg/mL (0-12 pg/mL), D-Dimer 29,578 ng/mL (0-622 ng/mL), fibrinogen 183 mg/dL (163-463 mg/dL), elevated INR 1.8 (0.9-1.1), and PT 20.9 (10.1-13.1 sec).
Chest x-ray showed bilateral multifocal patchy opacities (Fig. 1a), and a CT chest showed extensive patchy parenchymal airspace opacities involving all lobes of the lung (Fig. 1b and c). CT abdomen revealed diffusely heterogeneous enhancement and nodularity throughout the liver parenchyma, suspicious for liver cirrhosis. The pancreas and spleen had a healthy contrast-enhanced CT appearance.
She subsequently developed severe respiratory acidosis, as manifested on a blood gas (pH 7.24, pCO2 68.9), prompting intubation and transfer to the intensive care unit (ICU). She was then started on intravenous (IV) steroids due to high suspicion for DAH secondary to systemic vasculitis. Bronchoalveolar lavage after intubation was performed. The airways were observed erythematous, and the lavage was with a bloody return, confirming alveolar hemorrhage. The cytology exam demonstrated benign respiratory epithelium with reactive changes, acute inflammation, macrophages, and red blood cells. Acid-fast stain and cultures were negative, as well as a Pneumocystis jiroveci smear.
Further laboratory testing was negative for autoimmune disease, including normal IgG and IgM cardiolipin antibodies, normal Beta-2-Glycoprotein IgG and IgM antibodies, negative anti-nuclear antibodies (ANA), negative anti-neutrophil cytoplasmic antibodies (P-ANCA and C-ANCA), negative rheumatoid factor, and negative anti-glomerular basement membrane antibody. Infectious disease workups were also negative, except for the respiratory viral panel collected from a nasopharyngeal swap that confirmed the presence of human metapneumovirus by PCR. These tests included negative HIV-1/2 antibodies and HIV-1 antigen, negative Histoplasma galactomannan urine antigen, negative Legionella and pneumococcal urinary antigens, negative Epstein-Barr DNA PCR, negative hepatitis viral panel, negative Blastomyces dermatitidis antibodies, negative Aspergillus galactomannan antigen and galactomannan index, negative Mycoplasma, West Nile virus, cytomegalovirus and dengue virus serum IgM and IgG antibodies, negative blood cultures, negative urine cultures, and negative bronchial brushing cultures (including negative fungal cultures). The Illinois Department of Public Health was contacted for coronavirus disease 2019 (COVID-19) testing, but the request was denied as the patient did not meet the criteria for trial at that point. She had no history of recent travels, no sick contacts, and community transmission was not suspected in the State of Illinois at that time.
On admission day 4, she was started on vasopressors due to shock. On day 8, she was placed in a prone position for 24 h due to worsening hypoxia. On days 9 and 10, she required hemodialysis for severe acute kidney injury (creatinine 4.83 mg/dL) with acidosis (pH 7.21). On day 11 she developed disseminated intravascular coagulation (platelet count 19 k/mm3, D-Dimer 36,469 ng/mL and fibrinogen 91 mg/dL). CT head without contrast showed scattered small bilateral subarachnoid hemorrhages. She ultimately developed multi-organ failure, had a cardiac arrest, and was declared dead after unsuccessful attempts at resuscitation.