A 36-year-old right-handed woman presented with a few days' history of cough, diarrhea, and fever. Medical history was significant for hypertension and polycystic ovary syndrome, for which the patient took anti-hypertensive medications and oral contraceptives. A nasopharyngeal swab showed that the patient was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient was prescribed Azithromycin and sent home to quarantine.
On the 8th day of home quarantine, the patient was found to have right-sided weakness and facial droop and was brought to the emergency department 8 h post-ictus. She had sustained wakefulness and was able to localize to pain, and her pupils were equal and briskly reactive to light. She also had hemiplegia and right central facial palsy. The NIHSS score was 25. Cranial CT scan showed a hypodensity at the left ICA territory without midline shift and an Alberta Stroke Program Early CT Score of 0 [Figure 1]. She was admitted to the ICU and started on medical decompression. Admission D-dimer and C-reactive protein (CRP) were elevated.
A 24-h monitoring CT scan showed an increased degree of hypodensity in the left ICA distribution, as well as a midline shift of 7.3 mm. In view of this finding, DH was recommended, but there was no consent. Shortly after, the patient was found to have tachycardia, labored breathing, and decrease in sensorium. She was only able to open her eyes to painful stimuli and withdraw to pain, and her left pupil became dilated. She was intubated, and then brought to the operating room for DH after consent was secured. Postoperatively, the patient's sensorium improved, and she was able to open her eyes to speech and localize to pain. The anisocoria was reversed.
However, the patient continued to have fever, tachycardia, and tachypnea despite ventilatory support. Chest radiograph showed bilateral pneumonia with consolidation. The levels of the inflammatory markers D-dimer and CRP were higher than on admission, and ferritin and LDH levels were elevated as well. After 2 weeks, a repeat nasopharyngeal swab showed that the patient was negative for SARS-CoV-2. A tracheostomy was performed.
Over the course of her ICU stay, the patient also developed ventilator-associated Acinetobacter baumannii pneumonia and pulmonary tuberculosis. She had persistent desaturation and hypoxia, making it difficult to wean her off ventilatory support. The patient succumbed to chronic respiratory failure 25 days post-ictus.