An 88-year-old Hispanic woman with diabetes mellitus, hypertension, and reactive airway disease presented to the emergency department with a 3-day history of dyspnea. Associated symptoms included productive cough, subjective fevers, and generalized myalgias. The patient had recently returned from a trip to Mexico where she was exposed to multiple family members infected with SARS-CoV-2.
Vital signs at presentation included temperature 36.9 C, blood pressure 84/50 mmHg, heart rate 109 beats per minute, respiratory rate 25 breaths per minute, and oxygen saturation 97% on ambient air. Upon ambulation, patient experienced hypoxia with oxygen saturation 80% on ambient air. Physical examination was pertinent for positive bronchial breath sounds on the right chest.
Laboratory studies were significant for bandemia of 50%, lactic acid 2.5 mmol/L (reference range 0.4-2.0 mmol/L), procalcitonin 3.6 ng/mL (normal high <= 0.50 ng/mL; critical high > 1.99), and elevated inflammatory marker C-reactive protein (CRP) 4.99 mg/dL (normal high <= 0.30). Nasopharyngeal swab for SARS-CoV-2 RNA was reactive. Swabs from nares for influenza A and B antigens were negative. Chest radiograph revealed a 7-cm right upper lobe (RUL) opacity (Image 1). Subsequent computed tomography (CT) angiogram of the chest revealed a large RUL consolidation with air bronchograms, scattered ground-glass opacities, and mediastinal lymph nodes with no evidence of pulmonary emboli (Image 2(A) and (B)).
She was initiated on ceftriaxone 1 g intravenous (IV) every 24 hours and azithromycin 500 mg IV every 24 hours for suspected community-acquired pneumonia. She was started on prednisone 40 mg oral (po) daily in the setting of hypoxia and COVID-19. Bacterial sputum culture was ordered, however was, unfortunately, not collected for reasons that remain unclear. Coccidioidomycosis serology was negative, including nonreactive immunodiffusion for IgM and IgG as well as complement fixation titer <1:2. QuantiFERON tuberculosis gold test was also negative. In addition, 2 sputum acid-fast bacillus smears and cultures were negative. Preliminary routine blood cultures (aerobic and anaerobic bottles) grew Gram-negative diplococci in 1 of 2 bottles from 1 set and final culture revealed NM (Image 3(A) and (B)). Subsequently, ceftriaxone was increased to 2 g IV every 24 hours.
The patient remained alert and oriented and denied any headaches or neck stiffness. Neck was supple with no nuchal rigidity or signs of meningismus. Therefore, suspicion for meningitis was low and lumbar puncture was not performed. Bronchoscopy was considered, however was deferred given the patient's improvement in symptomatology with antibiotic therapy and in an attempt to reduce potential exposure to coronavirus by avoiding an aerosolizing procedure.
Repeat blood cultures revealed no growth. The patient remained on airborne isolation precautions while in the hospital and infection control was notified of the blood culture growing NM. After 5 days of ceftriaxone therapy, the patient was discharged home with supplemental oxygen at 2 L via nasal cannula for COVID-19-associated hypoxia. Results of susceptibility testing were not available at the time of discharge; however, per the Infectious Disease service recommendations, she was also discharged with 9-day supply of amoxicillin/clavulanic acid 875 mg/125 mg po twice daily to complete a total of 14 days of antibiotic therapy.
The NM sensitivities returned approximately 4 weeks after discharge. The isolate was sensitive to ceftriaxone, chloramphenicol, and meropenem but was resistant to ampicillin, levofloxacin, penicillin, and trimethoprim/sulfamethoxazole (Table 1). Patient was seen in the geriatric clinic approximately 3 months after discharge at which time her symptoms had completely resolved and she was no longer hypoxic. Repeat chest X-ray at 3 months demonstrated near-complete resolution of the previously noted RUL consolidation (Image 4).