A 21-year-old Afghan man presented to the emergency department with a 7-day history of fever, chills, hemoptysis and hematuria. He denied any recent exposure to any patient with COVID-19. He had no significant history of rheumatologic disorders or any other diseases. The patient had tachypnea and tachycardia on admission. He demonstrated normal blood pressure. Oxygen saturation was measured 86% in room air by pulse oximetry which reached 96% using the 60% venture mask. On examination, his lungs displayed bilateral coarse crackles. Electrocardiography findings were normal.
At the time of hospital admission, laboratory tests showed HGB: 14.7 gr/dl; WBC: 11.61x103/mm3; PLT: 162x103/mm3; D-dimer: 900 ng/ml; CRP: 12 mg/dl; ESR: 60. In arterial blood gas analysis, pH: 7.35, pCO2: 50.7 and HCO3: 27.3 were noted. Urine analysis was notable for protein: 1+; WBC: 12-14; RBC: 20-25 and blood: 2+. Other laboratory parameters were in normal ranges. No bacterial growth was seen in blood and urine culture. Respiratory mucus smear and culture were also negative for Mycobacterium tuberculosis and bacterial infection.
Due to his respiratory signs, a spiral computed tomography (CT) scan of lungs was performed which revealed evidences of bilateral ground glass opacity and multifocal consolidation distributed along the subpleural regions suggesting for COVID-19 (Figure 1 A-C). Reverse transcriptase polymerase chain reaction test for COVID- 19 was performed to confirm the diagnosis which showed positive result.
During hospitalization, hemoptysis and dyspnea worsened and the patient deteriorated. Since hemoptysis was uncontrolled and tachypnea was worsened, the patient underwent endotracheal intubation on the second day of hospitalization. Active airway bleeding was noticed during intubation.
Due to his concurrent hemoptysis and hematuria, the patient was suspected to have vasculitis. Therefore, rheumatologic tests including ANA, Anti ds-DNA, C ANCA, P ANCA, anti CCP, RF, SSA-RO and SSA-LA were performed for the patient. All the performed rheumatologic tests were negative. On the third day of hospitalization, laboratory examinations were notable for HGB: 13.7 gr/dl; WBC: 0.8x103/mm3(lymphocyte count was undetectable); PLT= 84x103/mm3; BUN=52 mg/dl; Cr=2.66 mg/dl, lactate dehydrogenase (LDH) =774 U/l and aspartate aminotransferase (AST)=50 U/l. Venous blood gas analyses showed a pH of 7.12; a PCO2 of 53.6 and a HCO3 of 17.2.
Despite supportive, anti-viral and antibiotic therapy, the patient died due to respiratory failure and multi-organ damage on the third day of hospitalization.