A 33-year-old female without comorbidity who had symptoms of the cold a week ago referred to treatment clinic for COVID-19 in Imam Reza hospital of Tabriz, Iran. After Polymerase chain reaction (PCR) test through the nasopharyngeal swab and radiologic examination, she was hospitalized. The symptoms worsened and she was intubated on the second day. The patient was also pregnant with a gestational age of 34 weeks. Lopinavir/ritonavir (200mg/50mg) two tablet tow times, Ribavirin 200mg every 6 h, and Oseltamivir 75mg tow times were given for the treatment of COVID-19. The medications used for treatment of pneumonia were Meropenem, Ciprofloxacin, Vancomycin. All doses of drugs were administrated by adjusted dose assuming the patient is anephric. This study have been approved by the Medical Ethics Committees of Tabriz university of medical sciences before patient enrollment and treatment (Approval ID: IR.TBZMED.REC.1398.1314).
The patient did not receive nephrotoxic drugs such as antibiotics before uremia, and when her BUN and Cr increased, the patient's urine became muddy brown and the volume of urine decreased, and we called it Acute kidney injury (AKI). In our urine sedimentation, there were a lot of granular casts along with cellular debris, which was interpreted as ATN. Due to the presence of urinary sedimentation and the presence of granuloma casts in the urine and muddy brown nature of urine, the diagnosis of ATN was more important than urinary toxicity. In spite of using Furosemide, urine output was 600 cc in 24 hours. After hemoperfusion, urine output reached above 2 L in 24 hours and we entered the polyuria phase.However, Vancomycin was eliminated and Linzolid started for the patient because it is not nephrotoxic.
Also, a few supplements were also prescribed after developing ATN including daily Rocaltrol and Nephrovit (as a multivitamin appropriate for patients with renal failure), Folic acid and Calcium carbonate. Vitamin C 250 mg is administrated by gavage. Hemoglobin and white blood cell at admission time were 11 mg/dl and 2400 per microliter, respectively; so that pancytopenia was diagnosed and suspected of having lupus erythematous. Therefore, rheumatology consultation was asked, all of lupus diagnostic criteria were negative but received Intravenous immunoglobulin (IVIG) 5 gr daily for 5 consecutive days after consultation with hematologist.
The patient did not have peripheral schistocyte in the blood, we did not make diagnoses such as microangiopathy (thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: TTP-HUS) and only Collagen vascular disease (CVO) due to anemia and vascular thrombocytopenia was evaluated. The patient's anemia and thrombocytopenia improved after hemoperfusion and the patient had an increase in hemoglobin and platelets. The patient's electrolytes were regularly monitored. As mentioned, due to the lack of schistocyte in the peripheral blood, microangiopathy was ruled out. Lupus tests including C3, CH50, Cu and Anti-dsDNA were negative. Primary LDH was 1360 that decreased to 380 after hemoperfusion. Serum glutamic oxaloacetic transaminase (SGOT) and Serum glutamic pyruvic transaminase (SGPT) were 78 and 46 units per liter of blood serum, respectively.
The patient's PCR test was positive, so a CT scan was taken and showed ground glass opacity (GGO) with consolidation in upper right lobe indicating lung involvement. Preoperative CT is presented when the patient was not intubated yet (Fig. 1). After admission, creatinine levels gradually increased up to 6.8 mg/dl accompanied by respiratory and metabolic acidosis in the arterial blood gas (ABG). The patient's respiratory rate increased to 36 breaths/minute and the patient was intubated. She underwent caesarean section after consultation with a gynecologist. he patient had to undergo dialysis 12 hours before caesarean section. The baby was negative for COVID-19 and was in good health. Due to the low platelet count, the patient entered the operating room with 10 platelet injections. Before surgery Hb was 7.25 mg/dl (Blood Pressure = 100/66 mmHg, prothrombin time (PT) = 16s, partial thromboplastin time (PTT) = 36s, Pco2 = 45 mmHg, Hco3 = 18 mEq/L).
After surgery, hemoglobin had reached 7.8 mg/dl, which inevitably received a unit washed packed cell, and hemoglobin is now 9.5 mg/dl. White blood cell (WBC) increased to 7,400 per microliter. On the sixth day of hospitalization, diuresis was established, and the patient's creatinine declined sharply. The patient's creatinine had reached 3 mg/dl and conservative treatment was launched. The patient is still hospitalized due to COVID-19 and is in the recovery phase with fluid control and does not receive medication for her ATN. The patient is still intubated with a fraction of inspired oxygen (FiO2) of 60% and Positive end-expiratory pressure (PEEP) of eight. SpO2 is 94% but the patient's ATN has been resolved. We started weaning the mechanical ventilation. The patient is conscious with full awareness to time, person and place. The maternal well-being is achieved and her neonate was discharged. Postoperative Chest-x ray is presented (Fig. 2). As shown, pneumonia is clear in the figure that's why the patient is giving Ciprofloxacin, Vancomycin and Meropenem now.