A 68-year-old woman presented to the emergency department of a referral hospital in Tehran, Iran, complaining of persistent non-productive cough, fever, and myalgia of three-day duration. She denied any history of rhinorrhea, sore throat, dyspnea, abdominal pain, vomiting, or diarrhea. She had a medical history of poorly controlled diabetes mellitus, end-stage renal disease for which she received hemodialysis three times a week, and rheumatoid arthritis. She had undergone coronary artery bypass grafting 13 years ago. Her medications included rosuvastatin 10 mg daily, prednisolone 5 mg daily, hydroxychloroquine 200 mg daily, aspirin 80 mg daily, and losartan 50 mg twice a day. She was also on a single daily injection of 18 units of lantus (insulin glargine) for diabetes mellitus.
Vital signs were as follows: body temperature 39.9  C, blood pressure 140/60 mmHg, pulse 105 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 90% on room air. Lung auscultation revealed mild bilateral rales. The remainder of the examination was unremarkable, and no weakness or sensory disturbance was noted at that time. A chest CT scan was performed, which revealed mild bilateral patchy high-density shadows in both lungs (Fig. 1A). Considering the clinical presentation of viral pneumonia in a patient at the time of the 2019 novel coronavirus outbreak, she was admitted to the hospital with a high suspicion for SARS-CoV-2 infection. An upper respiratory tract swab tested positive for SARS-CoV-2 on real-time RT-PCR assays within 48 h. Laboratory investigation on admission reflected white blood cells 8.5 x 103/uL with lymphopenia, hemoglobin 11.5 g/dL, platelets 175 x 103/uL, potassium 5.3 mEq/L, sodium 133 mEq/L, creatinine 12 mg/dl, ESR 15 mm/hr, and CRP 121 mg/L. Her blood sugar level was 400 mg/dL at the time of admission. Hepatic transaminases and bilirubin were within the normal range.
After admission, the patient received supportive care and management of symptoms, including oxygen supplementation, and compassionate therapy consisting of lopinavir/ritonavir 400/100 twice a day, and oseltamivir 30 mg daily as per the Iranian interim guidelines for the management of COVID-19 at that time. Other than her routine medications, novaRapid (insulin aspart) 4 units three times a day was added to her regimen.
On day 3 of hospitalization, while the patient's vital signs remained stable and O2 saturation was 94% breathing room air, she started to develop generalized hypotonia in lower extremities. There was bilateral weakness on motor examinations, and deep tendon reflexes were absent. Her cranial nerves were normal, and other neurological examinations were unremarkable. Lumbar puncture was performed by a neurologist, which failed to yield any CSF in two repeated attempts. MRI of the whole spine, nerve conduction velocity (NCV), and electromyographic (EMG) studies were requested. After discussion, the neurologist decided to proceed with the administration of methylprednisolone 250 mg IV for possible virus-related immune reaction provided that her blood sugar and electrolytes were controlled.
On day 6, she started having difficulty breathing, and her O2 saturation dropped to 78% as her respiratory status deteriorated gradually. A chest CT scan taken at the time demonstrated severe bilateral ground-glass opacities consistent with acute respiratory distress syndrome (ARDS, Fig. 1B). She was intubated and mechanically ventilated in response to respiratory distress. However, she developed cardiac arrest and, unfortunately, died on the same day after multiple resuscitations attempts.