ABSTRACT
We describe a case of a SARS coronavirus 2 (SARS-CoV-2) infection in a Swiss 54-years-old immunocompromised patient (lymphoma, therapy with the anti-CD20 antibody Rituximab® ), with initial scarce respiratory symptoms but typical coronavirus disease 2019 (COVID-19) radiological presentation, and symptoms onset during a holiday trip to Texas (USA). Three nasopharyngeal swabs in the 96 hours following hospital admission were negative, despite a CT thorax suggestive for an early stage of infection. COVID-infection was finally confirmed in the bronchoalveolar lavage (BAL) fluid, performed for exclusion of an alternative diagnosis in immunocompromised. In the BAL an increased cellularity with marked lymphocytosis of 35%, a reduced CD4/CD8 ratio of 0.1 and borderline neutrophilia of 3% were found. This finding might be due to the concomitant therapy with anti-CD20 antibodies, but the presence of lymphocytosis in the BAL despite peripheral lymphopenia with decreased CD4/CD8 T-cells ratio are described here for the first time in a SARS-CoV-2 infection. Persistent gastrointestinal symptoms (diarrhea), fever and initially headache were the predominant symptoms. The respiratory symptoms were scarce (variable mild dyspnea mMRC1). The respiratory conditions worsened during the hospital stay, with tachypnea up to 35/min, increased need for supplemental oxygen up to 8 L/min and worsening lung infiltrates on CT thorax on day 5. A therapy with hydroxychloroquine (HCQ) and an immunoglobulin-supplementation were given, with clinical and respiratory improvement, without need for intensive care or any ventilator support, and hospital discharge on day 16. Our case highlights some diagnostic and therapeutical challenges occurring in patients with COVID-19 infection. As take-home message, in the presence of clinical and radiological findings compatible with SARS-CoV-2 infection we outline the importance of treating patients accordingly, also in presence of repeated negative nasopharyngeal swabs. In selected patients as in our case a bronchoscopic BAL should be considered to exclude other infections, but in our opinion not primarily to confirming COVID-19 infection. Our unique finding of a lymphocytosis in the BAL during a COVID-19 infection needs further investigations.
ABSTRACT
The SARS-CoV-2 virus (COVID-19) was initially observed in a group of Chinese patients with unclear pneumonia in Wuhan, Hubei [1] in late December 2019. The first positive case in Switzerland was confirmed on 25 February 2020 in a patient from canton Tessin, who most likely caught the virus during a visit to Milan, Italy [2]. The country has since been preparing for an imminent public health emergency caused by the pandemic. As of 14 May 2020, the Swiss healthcare system is facing a total of 30,463 corona virus-positive people [3]. With numbers of new infections decreasing after the first pandemic wave, the continuing endemic situation will continue to be a major challenge for the Swiss healthcare system. It remains crucial to separate the clinically low-symptomatic from the severely affected patients in order to offer a specific therapeutic strategy to every SARS-CoV-2 patient. Reports from Chinese cohorts describe an increasing role of imaging strategies in the detection and surveillance of COVID-19 patients because of insufficient testing sensitivity of real-time reverse transcription polymerase chain reaction (RT-PCR) tests [4]. Chest computed tomography (CT), with a reported sensitivity of up to 97% [5, 6], gained importance particularly in patients with false negative RT-PCR results. In this short communication, we describe our first clinical experiences with 55 COVID-19 patients in Central Switzerland, who were either imaged with a standard chest x-ray, chest CT, or both. We provide an illustrative and schematic description of typical COVID-19 imaging features and suggest that imaging plays an important role in the clinical work-up of suspected or confirmed COVID-19 patients. This study was approved by the national ethics review committee (EKNZ, Switzerland) and patients’ informed consent was waived.