A 28 years old female patient, with a six months history of a chronic myeloid leukaemia (CML) treated by tyrosine kinase inhibitors leading to clinical and biological improvement, was admitted in the hematology ward on the 28th of June, due to a 4 days history of diarrhea and fever up to 40 C. White blood cell count showed a leukocytosis of 100000 el/mm3, with a blast percentage of 90%. A bone marrow aspiration and immunophenotyping were realized and revealed a blastic transformation of her CML into an acute myeloid leukaemia (AML) M4 subtype. A chest X-ray was performed as part of the septic workup showing a right lower lobe pneumonia, followed by a chest CT scan (Figure 1) showing bilateral condensation and ground glass opacities in favor of an infectious pneumonia associated with a small amount of fluid in the right pleural cavity. The patient received antibiotics and a first cure of chemotherapy.
As routine evaluation in all patients with hematological malignancies, the patient was tested for SARS-CoV-2. Reverse transcriptase polymerase chain reaction (RT-PCR) from nasal and pharyngeal swab came back positive. Following a deterioration of her general health status, the patient was transferred to the ICU on the 2nd of July for SARS-CoV-2 pneumonia. Upon admission, the medical examination revealed a conscious patient (GCS 15/15), respiratory rate at 46 cycle per minute, oxygen saturation (SpO2) of 70% at room air and 95% upon wearing a non-rebreather face mask (15 L/min), blood pressure of 100/50 mmHg, pulse of 110 bpm and a temperature of 40 C. Complete blood count showed a leukocytosis, white blood cells of 158140 el/mm3, neutrophils of 1580 el/mm3, lymphocyte of 6330 el/mm3, anemia with a hemoglobin at 6.2 g/dl, thrombocytopenia with platelets of 32000. Blood hemostasis analysis showed a biological disseminated intravascular coagulation (DIC), prothrombin time at 48% and partial thromboplastin time at 39.7 sec, fibrinogen at 2.58, D-dimers at 6700 mg/l. Biochemical profile showed an hypokalemia of 1.5 mmol/l, CRP of 106, PCT of 1.68, ferritin at 2000 ng/l and troponins at 70 ng/l, without any tumour lysis syndrome was absent: uric acid< 5, LDH at 3271 UI/l, potassium at 1.5 mmol/l, phosphorus at 27 mg/l, calcium at 85 mg/l. A pretherapeutic EKG showed a sinus tachycardia at 100 bpm, no repolarization trouble and a normal QTc at 464 ms. The echocardiography showed: for the left ventricle: normal in size with normal wall thickness and systolic function, an ejection fraction at 50%, without neither dyskinesia nor thrombosis. For the right ventricle: no valvular leakage or stenosis, a right ventricle systolic function associated with a concentric left ventricular hypertrophy. Both aorta and the inferior vena cava are normal.
An infectious workup, consisting of urine cytobacteriological examination, stool tests, a PCR based detection of mycobacterium tuberculosis, blood cultures and aspergillus serology all came back negative. Therapeutic management included oxygen therapy, non-invasive ventilation at 50% FIO2 (PEP at 5 and IA at 12). Medical treatment associated hydroxychloroquine 200 mg 3 times a day, azythromycin 500mg the first day then 250mg per day, methylprednisone at 80mg a day for 7 days and curative anticoagulation treatment including enoxaparin 100 UI/kg (1mg/kg) twice a day. On day 3, the patient was eupneic (SpO2of 98%) wearing nasal cannula at 3L/min, she no longer needed sessions of non-invasive ventilation. One week later, the patient had a favorable clinical and radiological (Figure 2) outcome and was declared cured of the SARS-CoV-2 infection following a negative PCR test, she was transferred back to the hematology ward for further treatment of her acute myeloid leukaemia.