On the 14th of March 2020, a 36-year-old gentleman presented at the emergency unit of a nearby hospital with fever, dry cough, and head and limb aches that started three days earlier. In good physical condition and otherwise healthy, he had completed a half-marathon the week before, but on admission to another hospital, he presented with reduced general condition and shortness of breath. Physical examination revealed crackles in the right upper lobe upon auscultation. Medical, family, and psychosocial history was completely unremarkable.
As SARS-CoV-2 was suspected, he was immediately admitted to the ICU. He received microbiological and virological sampling as well as chest X-ray and thoracic CT. A calculated antimicrobial chemotherapy with piperacillin/tazobactam (3 x 4.5 g/d i.v.) and clarithromycin (2 x 500 mg/d i.v.) was started. Polymerase chain reaction (PCR) for SARS-CoV-2 was negative, as were the results for influenza, Mycobacterium tuberculosis, and Legionella spp. After 2 days, the antimicrobial regimen was changed to meropenem (3 x 1.0 g/d i.v.), linezolid (2 x 600 mg/d i.v.), and fosfomycin (3 g/d i.v.) due to persistently elevated inflammatory parameters and further clinical deterioration. The assumption of the patient having COVID-19 was maintained. Imaging of the lungs revealed a diffuse interstitial reticular pattern, multilobular patchy ground-glass opacification, and consolidation of the right upper lobe.
After a week on high-flow oxygen, he deteriorated and was intubated at an oxygenation index (PaO2/FiO2 ratio) of 130. Despite proning, he deteriorated further (hypercapnia with respiratory acidosis and hypoxemia with a PaO2/FiO2 ratio 108), needing higher doses of vasopressors, and our hospital's extracorporeal membrane oxygenation (ECMO) team was called on the 22nd of March 2020 to transfer the patient. The patient was reported as having COVID-19 and moderate ARDS with respiratory acidosis.
The ECMO team set out to transfer the patient under COVID-19 personal protective equipment (PPE). In the external hospital, after reviewing the laboratory and imaging findings, as well as the ventilator settings, the team leader decided against implanting an ECMO on site, and the patient was transferred under COVID-19 precautionary measures. Bronchoscopy with bronchoalveolar lavage (BAL) was performed for microbiological sampling and to further elucidate the hypothesis of an infection with SARS-CoV-2. Additionally, a naso- and oropharyngeal swab for SARS-CoV-2 was obtained.
Chest radiographs were reviewed, and a new chest X-ray was made (Figure 1). Imaging showed mainly right-sided pneumonia, not typical for COVID-19, and the hypothesis of COVID-19 was abandoned. Antimicrobial therapy was changed, as atypical pneumonia was suspected. Meropenem (then given continuously i.v., monitored by determination of serum levels) was continued for a total of 7 days, and clarithromycin (2 x 500 mg/d) was added to the antimicrobial regime again (Table 1). Remarkably, for a young and otherwise healthy individual, the patient had elevated bilirubin and LDH levels, with diminished haptoglobin and macrocytic hyperregenerative anemia (hemoglobin 5.3 g/dL at a scvO2 of 67%) on admission, demonstrating hemolysis. Coombs' test revealed cold agglutinins the same day.
Microbiological results from a BAL (March 22nd) were negative for SARS-CoV-2, Pneumocystis jirovecii, Bordetella pertussis and B. parapertussis, Chlamydophila pneumoniae, Haemophilus influenzae, Legionella pneumophila, Moraxella catarrhalis, and Streptococcus pneumoniae; however, the patient tested positive for Mycoplasma (M.) pneumoniae. Thus, a diagnosis of mycoplasma-related ARDS with cold agglutinin disease was made. The patient was in total substituted with 4 units of packed red blood cells and received only warm infusions. Ventilator support was deescalated soon after change of the antimicrobial regimen, and the patient was extubated on March 25th receiving noninvasive ventilator support for 4 more days with supplementary oxygen up to 40%. Meropenem was continued for a total of 7 days, and clarithromycin (2 x 500 mg/d) was added to the antimicrobial regime again (Table 1). Hemolysis improved quickly under the antibiotic regime. The patient was discharged from the ICU on March 30th and was discharged home without supplementary oxygen on April 6th. He had no health-related complaints in a telephone interview conducted on June 18th.