ABSTRACT
Background: Often the onset symptoms of a disease don't easily direct towards the correct diagnosis. Furthermore, the CoViD-19 pandemic has often been an obstacle to obtaining a quick diagnosis. Description of the case: Male 49-year-old patient admitted to emergency room for persistent back pain, asthenia and weight loss. Physical examination revealed a palpable mass in the right gluteal region, chest X ray an enlargement of mediastinum. Nasopharingeal swab for CoViD-19 was positive (even if negative for CoViD-related symptoms);he was so hospitalized in our Internal Medicine CoViD Ward. Blood samples found microcytic anemia (thalassemic trait carrier);high ferritin (1072 ng/ml), aptoglobin (297 mg/dl, nv <200) and B2 microglobulin (3.25 mg/l, nv <2.53);K and L chains normal with K/L serum ratio reduction, increase in urine sample. Lymphocyte subpopulations were indicative of lymphopenia. Suspecting a lymphoproliferative disease, he performed a chest and abdomen CT scan that found: multiple bilateral pulmonary nodules, the largest one 10x9 cm in the left lung;a left renal lesion11x10 cm;a mass 9.5 cm of the sacroiliac left wing and splenomegaly (145 mm). We thus performed a US-assisted biopsy of the mass in the gluteal region. The histological examination allowed to identify metastasis from clear cell renal carcinoma. Conclusions: We report this case to highlight the peculiarity of onset of this renal carcinoma, in absence of genitourinary symptoms. Diagnostic autonomy can be a winning weapon in accelerating the diagnostic process, even more so in times of CoViD-19 pandemic.
ABSTRACT
Background: COVID19 pneumoniae presented, especially at thebeginning of pandemia, diagnostic difficulties dues to the frequentswabs negativity (in contrast with clinic and imaging) and the notwidespread availability or doubtful interpretation of serologicaltests. Clinical case: 52 years old man with cough and fever for a week,admitted to our Medical Ward for acute respiratory failure onMarch 24, 2020. Positive history of epidemiological contact, obesity and hypertension. Laboratory tests showed an increase in PCR,LDH and ferritin. EGA showed pO2 62%, pCO2 37% and P/F 298and oxygen therapy was started (Venturi mask 6 l/min). Chest Xray was positive for interstitial pneumonia. Lung ultrasound showeddiffuse B lines (especially in posteral basal fields) and irregularpleural line with small subpleural thickenings. Despite a first negative swab, we considered the patient affected by Covid19 pneumoniae and started therapy: hydroxychloroquine 600 mg die,azithromycin 500 mg die and fondaparinux 2.5 mg die for 7 dayswith rapid clinical improvement. Swab repeated after a week wasnegative but COVID19 search in sputum was doubtful two times.Diagnosis was definitely confirmed three weeks after discharge,when our laboratory was finally able to perform serological testsfor COVID 19 on blood samples collected at the admission. BothIgM and IgG were high titer positive.Conclusions: This case report highlights how COVID19 pneumoniae diagnosis needs combination of epidemiology, clinical manifestations, laboratory tests, imaging and how swab negativity can'texclude it.