ABSTRACT
Since the beginning of the SARS CoV-2 pandemic two years ago respiratory complaints have been one of the most common presenting symptoms to the emergency departments across the United States. At this time, over 45 million Americans have tested positive for the SARS CoV-2 virus and the vast majority of the patients who present to the hospital with this infection are due to the consequences of systemic inflammation, most significantly in the lungs. We would like to share a case of a 79 year old female with known cystic lung disease (suspected Pulmonary Langerhans Cell Histiocytosis) on 4L oxygen via nasal cannula (NC) at baseline who presented to a community hospital from her nursing facility for hypoxia. Upon presentation to the hospital she was found to test positive for the SARS CoV-2 virus. In the course of her work up she received a CTA of the chest which did show mild ground glass changes consistent with a mild viral pneumonia, more significantly, the scan revealed numerous pulmonary arterio-venous malformations (AVMs) in bilateral lower lobes that were not present on previous imaging of the chest. A detailed work up of the patient was unable to be performed due to the patient declining invasive testing and wishing to pursue hospice. The patient was found to have an estimated shunt fraction >30% with a cardiac echo that confirmed an intrapulmonary shunt and an acute drop in the patient's left ventricular ejection fraction (LVEF) due to an NSTEMI 3 months prior to admission. We believe that this patient had underlying hereditary hemorrhagic telangiectasia resulting in pulmonary AVMs that were minimally symptomatic until the patient's acute drop in her LVEF which led to a drastic increase in her intrapulmonary shunt fraction.