At 19:00 on February 16, 2020, a 38-year-old man suffered a sudden disturbance of consciousness during dinner and fell to the ground. He could not be awakened, could not speak, accompanied by vomiting, no abnormal limb movements and convulsions, and no incontinence. After onset, the family sent him to the local town health center. After symptomatic treatment, the patient's symptoms did not get better, so the patient was transferred to the local people's hospital for emergency treatment. Computed tomography (CT) examination of the brain revealed a large amount of cerebral hemorrhage, and the family was informed that the patient was in critical condition (Fig. 1).
At 15:00 on February 17, the patient presented with difficulty breathing and poor blood oxygen saturation. After endotracheal intubation, breathing was assisted by ventilator. For further treatment, the patient was transferred to the cerebrovascular disease treatment center of our hospital at 21:00 pm.
The patient's past history was obtained by asking family members: physical fitness, denying the history of hypertension, diabetes, and heart disease; denying a history of hepatitis B and tuberculosis; denying a history of food and drug allergies; and denying a history of trauma and surgery. Contact history of the epidemic area and close contact history of COVID-19 confirmed patients were denied. Physical examination: T 36.8  C, P 65 times/min, R 15 times/min, BP 155/106 mmHg, acute physiology and chronic health evaluation scoring systemII (APACHE II) scoring 16 points, conscious coma, endotracheal intubation, indwelling urinary catheter, examination cannot cooperate. There was no trauma or deformity in the skull, the pupil was unequal on both sides, the diameter of the left side was 3.0 mm, the diameter of the right side was 2 mm, and the light reflection was weakened. The neck was soft, the breath sounds in both lungs were rough, moist rales could be heard at the bottom of the lungs, the heart rhythm was uniform, no obvious murmurs were heard in the auscultation area of each valve of the heart, the abdomen was soft, and the liver and spleen were not touched. There was flexion in the left limb tingling, muscle strength level 3, poor response in the right limb tingling, muscle strength level 1, increased muscle tension, and the right Barbinski sign was positive.
Examination data showed: white blood cells (WBC) 13.19x109G/L, neutrophil absolute value (NE#) 12.06x109G/L, neutrophil percentage (NE%) 91.5%, lymphocyte absolute value (LY#) 0.39x109G/L, lymphocyte percentage (LY%) 2.9%, and high sensitivity C-reactive protein (hsCRP)70.7 mg/L. Emergency cranial CT examination showed that there were large irregular high-density lesions in the left temporal lobe, basal ganglia, and radiating coronal area, with uniform density and clear edges, the maximum layer size was about 8.5 x 4.2 cm, there were large patches of low-density edema around, the left ventricle was compressed and deformed, and the midline structure was shifted to the right; high-density shadows were seen in the bilateral ventricles. Conclusion: the left temporal lobe, basal ganglia, and radiation coronal hematomas break into the ventricles and brain hernias were formed. Chest CT results showed that there were cords and strip-shaped high-density shadows on the upper and lower lobe of both lungs, and the state was blurred; no abnormal density shadows were found in the remaining lungs. Endotracheal intubation, clear hilar structure, no displacement of the mediastinum, no obvious enlarged lymph nodes, no pleural effusion. Conclusion: sedimentary inflammation in both lungs.
At 23:00 on February 17, in order to remove the intracranial hematoma, after informed consent and signature by the patient's family, the operation was performed under general anesthesia: removal of left intracerebral hematoma + decompression of the left cranial flap + dura meningiotomy. During the operation, a dark red blood clot was seen in the left basal ganglia, and the clot was removed. No aneurysm and vascular malformation were seen during the operation. One drainage tube was placed in the hematoma cavity. After removing the bone flap, a second drainage tube was placed outside the dura mater, and the muscle, subcutaneous, and scalp were sutured, and the drainage tube was fixed. Safe transfer to intensive care unit (ICU) after surgery. Continue to use ventilator to assist breathing, oxygen inhalation, electrocardiogram (ECG) monitoring, anti-infection (Flucloxacillin), hemostasis (Aminocaproic acid), dehydration (Mannitol), brain protection, prevention of epilepsy, and other treatments, as well as symptomatic support treatment, and closely observed the changes of consciousness and pupil (Fig. 2).
On February 18, the patient had a high fever with a body temperature of 39.6  C, Re-examination of the craniocerebral CT revealed that: post craniocerebral operation, intracranial gas was accumulated, a drainage tube was placed, part of the left frontal parietal temporal bone was missing, and the left temporal lobe, basal ganglia, and radiative coronal area showed patchy high-density lesions, which were significantly reduced compared with the previous (February 17, 2020). The center line structure was less offset to the right than before; high-density shadows on both sides of the ventricle were slightly reduced compared with before. The scalp soft tissue was swollen and gas was accumulated. Re-examination of the chest CT showed that there were patches and strip-like high-density shadows on the back of both lungs, with a blurred state and partial consolidation, which was more than before (February 17, 2020). Considering the aggravation of lung infection, meropenem was used to continue anti-infection treatment.
On February 19, the patient still had high fever, excessive phlegm, and low blood oxygen saturation. Rough breath sounds could be heard at auscultation, and both lung breath sounds were low. Asked the family members of the patient to know that the close contact history of COVID-19 could not be completely ruled out. COVID-19 should be considered in combination with the patient's chest CT, which showed pulmonary interstitial inflammation, blood routine lymphocytic reduction, and poor anti-bacterial treatment effect, etc. Then the patient samples (pharyngeal swabs, sputum, serum, and stool) were taken for real-time fluorescence quantitative reverse transcription-polymerase chain reaction (rRT-PCR), and SARS-CoV-2 antibody-IgG and IgM tests were completed; the results were negative.
On the 20th, the patient's blood oxygen saturation could not be maintained, dyspnea was aggravated, and sputum was difficult to be sucked out. Then, tracheostomy was performed under local anesthesia, and the ventilator was used to assist breathing. In order to further improve the positive rate, the re-examination of sputum results showed that the SARS-CoV-2 nucleic acid test was positive. The COVID-19 consultation expert group considered: combining epidemiology, lymphocytic decrease, increased CRP, pulmonary interstitial inflammation, and SARS-CoV-2 nucleic acid positive; COVID-19 could be confirmed. In treatment, Abidol combined with Ribavirin antiviral, Alpha-Interferon nebulization treatment, thymosin to enhance immunity, and continued anti-infective treatment. Nursing: paid attention to strengthening airway management, strengthening atomization, sucking sputum in time, and turning back and patting frequently.
On February 24, the patient developed high fever again with a body temperature of 38.8  C (Fig. 3). The cerebrospinal fluid became turbid as before. The examination showed that the cerebrospinal fluid (CSF) was dark red, no clot, protein was 2.5 g/L, sugar was 1.85 mmol/L, and white blood cells were 673 x 106 G/L, among which multinucleated cells accounted for 95% (Table 1). Cerebrospinal fluid test results showed intracranial infection; the first consideration was SARS-CoV-2 intracranial infection. Check the cerebrospinal fluid SARS-CoV-2 nucleic acid RNA, and the result was negative. Continue to give antiviral and antibacterial treatment.
On February 25, in order to alleviate the patient's condition, with the consent of the patient's family, 150 ml plasma of type A Rh positive COVID-19-convalved patient was given. Re-examination of the brain CT showed that the scope of the patchy high-density foci in the left temporal lobe, basal ganglia, and radiating coronal region was approximately the same as before, the density was lower than before (2020-2-18), and the midline structure shifted to the right was less than before; the density of bilateral ventricles was slightly reduced. Re-examination of the chest CT results showed that there were patches and strip-shaped high-density shadows on the back of the two lungs, with a blurred state and partial consolidation, which was reduced from the previous (February 18, 2020).
On February 27, after the patient was infused with COVID-19 convalescent plasma, the symptoms improved, the body temperature decreased, and the dyspnea decreased. Both SARS-CoV-2 nucleic acid tests were negative (24 h interval), suggesting that antiviral treatment was effective. However, in the afternoon of the same day, the patient developed hyperthermia again, and his body temperature reached 39.2  C; considering the central hyperthermia, the patient improved after depyrexia treatment.
On February 29, the patient did not have high fever again, the results of the cerebrospinal fluid review showed that it was light red, no clot, protein decreased to 0.8 g/L, sugar increased to 4.45 mmol/L, and white blood cells decreased to 37 x 106G/L, of which monocytes accounted for 74%. This indicated that the intracranial infection was better than before.
On March 2, for several days, the patient's temperature was around 37.2  C. A review of cranial CT showed that the range of patchy high-density lesions was narrower than before (2020-2-25), the left ventricle was compressed and deformed, the degree to which the centerline structure shifts to the right was lessened than before; high-density shadows in the ventricle were slightly reduced, the soft tissue swelling of the scalp was more obvious than before. Re-examination of the chest CT showed that there were patches and strip-like high-density shadows on the back of both lungs, with a blurred state and partial consolidation, which was more than before (February 25, 2020). Review of CSF: CSF was pink, no clots, protein decreased to 0.59 g/L, sugar 3.47 mmol/L, slightly lower than before, white blood cells rose to 102 x 106G/L, mononuclear cells accounted for 60%. The patient's cerebrospinal fluid showed improvement, and since the two re-examinations of SARS-CoV-2 nucleic acid test was negative, and the antiviral treatment with Abidol, Ribavirin, and Oseltamivir had reached the course of treatment, so it was discontinued.
On March 5, the patient developed hyperthermia again, the body temperature reached 39.5  C, and the cerebrospinal fluid with clots was drained from the lumbar cistern. The test results showed that the cerebrospinal fluid was light red with clots, protein significantly increased to 4.28 g/L, sugar decreased to 0.01 mmol/L, and white blood cells increased to 172 x 106G/L, among which polykaryotic cells accounted for 60%. The cause of fever was considered to be intracranial infection; gram-negative bacilli were more likely. Continue treatment against infection.
On March 7, the patient developed high fever, up to 41  C, and the body temperature was not easy to control. The cerebrospinal fluid was yellow with clots, protein 4.29 g/L, glucose 0.4 mmol/L, and white blood cells increased to 5327 x 106G/L, among which polykaryotic cells accounted for 82%. The patient had a clear history of cerebral hemorrhage, pus was drained from the lumbar cistern drainage tube, and cerebrospinal fluid analysis indicated pyogenic infection, especially the drug-resistant gram-negative bacilli. Clinical pharmacists suggested meropenem combined with rifampicin to fight the infection. Yeast was cultured in the patient's sputum, and the possibility of fungal infection could not be ruled out, and voriconazole antifungal treatment was added. In addition, central fever needs to be considered.
On March 8, the culture results of cerebrospinal fluid showed acinetobacter baumannii. Considering opportunistic pathogenic infections, after in-hospital consultations, tigecycline and cefoperazone and sulbactam were given intrathecally by intrathecal injection, and oral minocycline. Continue to use voriconazole against fungus.
On March 10, dark red substances were drained from the gastric canal and black stools were observed in the patient, considering gastrointestinal bleeding, hemostatic drugs were administered, low-temperature noradrenaline dilution solution and low-temperature thrombin solution were injected into the gastric canal respectively, but the effect was poor.
On March 11, the patient still had gastrointestinal bleeding, and his body temperature was 37.5  C. Brain CT examination showed that the range of patchy high-density lesions was significantly smaller than that before (March 2, 2020), the patchy low-density shadows were increased, and the left brain tissue was significantly swollen; the left ventricle was compressed and deformed, and the scalp soft tissue was swollen. Re-examination of the chest CT showed that there were patches and strip-like high-density shadows on the back of both lungs, with a blurred state and some consolidation, which was more than before (March 2, 2020). In order to alleviate the condition and supplement the patient's coagulation factors, 200 ml of type A Rh-positive plasma was given after the consent of the patient's family. The patient's gastrointestinal bleeding stopped and the temperature gradually returned to normal. The re-examination of SARS-CoV-2 nucleic acid test was still negative on March 19, 2020.