A 28-year-old male with no previous comorbidities and no interstate travel history was admitted with complaints of fever, dry cough and breathlessness on exertion for a duration of 3 days. General physical examination of the patient was normal except fever of 100 F. He was maintaining saturation of 95% on room air at rest and post exercise, there was no dip in saturation.
A nasopharyngeal and throat swab was taken for SARS-COV-2 and it tested positive. Hematological parameters showed pancytopenia with a Total Leucocyte Count of 3800/mm3, Hemoglobin of 9 gm% and mild thrombocytopenia of 1,30,000/mm3. Chest Radiograph was normal. Electrocardiography was normal sinus rhythm with QTc interval of 380 ms. He was diagnosed with Coronavirus disease 19 (COVID-19). His fever subsided after 5 days of symptomatic treatment.
However, after 3 days of an afebrile period, he again started mounting fever. There was a generalised erythematous rash with papules over the extremities and face along with mucosal involvement [Figure 1a]. Oral mucosa was involved in the form of painless ulcers. Work up for fever including Dengue Ns1Ag, Dengue serology and Blood for Malarial Parasite was negative. Serology for Scrub Typhus and Leptospira was negative. Urine Routine and microscopic examination were normal. Blood culture and urine culture showed no growth. His repeat nasal and throat swab test for SARS-COV-2 was negative. Viral markers including HIV, HBsAg and Hepatitis C were negative. CRP levels were 25 mg/L and IL6 levels were 15 pg/mL.
His pattern of fever was continuous in nature with a maximum spike of 102.8 F. He underwent CECT Chest and Abdomen to look for secondary infections. It revealed Ground glass haziness involving bilateral lower lobes and patchy areas of consolidation involving bilateral upper lobes [Figure 2a, b]. Sputum examination for Gram stain, Acid Fast Bacilli, and Fungal stains were negative. Sputum culture for bacteria and fungi yielded no growth. He was empirically treated with broad spectrum intravenous antibiotics and it was de-escalated as serum procalcitonin levels were normal. During examination, lymph node enlargement was found in axillary and cervical regions. Lymphadenopathy was soft, non-tender, discrete and non-matted. In view of pancytopenia and persistence of fever, he was worked up for Secondary hemophagocytic lymphhistiocytosis (sHLH). Levels of Serum ferritin and Serum triglyceride were 680 ng/ml and 118 mg/dl, respectively.
Bone marrow examination showed reactive marrow without any features of hemophagocytosis. No granulomas or blast cells were seen. He underwent a Fine needle aspiration of the Cervical lymph node. It tested negative for GeneXpert MTB. Cervical lymph node biopsy showed follicular hyperplasia with no evidence of granuloma/malignancy and no features of hemophagocytosis. Based on the HS score probability of him suffering from HLH was less than <1%.
As a part of the work up for PUO, testing of Antinuclear antibody (ANA), Rheumatoid arthritis (RA) factor was done. ANA titres by Enzyme immunoassay (EIA) were significantly high 208.79 units (>60: Strongly positive). RA factor was negative. Extractable nuclear antigen antibody profile by EIA showed positivity to Smith (Sm), anti-double standard DNA. C3 and C4 complement levels were low. Immunological work up at tertiary care center revealed positive ANA by Indirect immunofluorescence (IIF) method (4+ Speckled). Based on EULAR 2019 criteria, he was diagnosed to be suffering from SLE, triggered by COVID-19. He was started on a daily dose of Tab HCQS 300 mg once daily (OD), Tab Prednisolone 10 mg OD and Tab Azathioprine 75 mg OD. He showed a favourable response to treatment. Fever subsided and skin rash resolved [Figure 1b]. Repeat CECT Chest showed normal scan with complete resolution of ground glass haziness [Figure 2c, d] and there was a significant decrease in cervical and axillary lymph nodes. His pancytopenia resolved and weakness subsided. During follow-up visit at the completion of 1 year, ANA positivity was persistent by IIF and he was asymptomatic on immunomodulatory therapy.