High-Altitude Pulmonary Edema Precipitated by Sars-Cov-2 Infection: A Case Presentation

ABSTRACT

Ladakh is a high-altitude area of India, with its altitude ranging from 2500 to 6000m, and it has been one of the famous tourist destinations for explorers, trekkers, and 6 of 24 mountaineers. Every year a large number of tourists, as well as laborers, visit Ladakh, risking their lives to highaltitude illnesses ranging from acute mountain sickness to fulminant high-altitude cerebral edema and high-altitude pulmonary edema (HAPE). HAPE is a life-threatening altitude illness that usually occurs in insufficiently acclimatized climbers in the first few days at altitudes >2500m. Apart from genetic susceptibility, mode, and rate of ascent, upper airway infections pose a risk determinant of HAPE. The hallmark of HAPE is hypoxic pulmonary vasoconstriction. Symptoms of HAPE are incapacitating fatigue, dyspnea at a minimal effort that advances to dyspnea at rest, and dry cough progressing to productive cough expectorating pinkish frothy sputum. The main modalities of treatment are immediate descent to lower altitude areas, hyperbaric oxygen therapy, and pulmonary vasodilator. For prophylaxis, slow ascent at the rate of 300m/day and acetazolamide 500mg/day 2 days before ascent is recommended. The objective of this report is to know the diagnostic and therapeutic approach of HAPE since it is confused with other pathologies presenting with respiratory failure. Little is known about viral infections as a risk factor for HAPE. Emphasis has been given to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as a risk determinant for HAPE, which is a rare case. To date, there is no study on SAR-CoV-2 as a risk determinant of HAPE. We report here a case of a 35-year-old young male, laborer from Bihar (India) with previous high-altitude experience ascending to Leh Ladakh on July 16, 2020 by flight. He got admitted to SNM Hospital Leh on July 24, 2020 with complaints of fever, body aches, and pain 2 days before ascending. After 3 days at altitude, he also developed a cough, which was initially dry but within a few days became productive with expectoration of pink frothy sputum. He also developed breathlessness on exertion, progressing to severity at rest within few days. There was no history of chest pain, orthopnea, and paroxysmal nocturnal dyspnea. General physical examination revealed Glasgow Coma Scale of 15/15, sick looking, respiratory rate of 24 breaths/min, oxygen saturation (SpO2) of 65% in room air, blood pressure of 110/70mmHg, pulse rate of 120 b/min regular, and temperature of 99.8 F. Chest examination showed bilateral coarse crackles on auscultation. The rest of the systemic examinations were unremarkable. Chest radiograph revealed bilateral patchy nonhomogenous alveolar opacities more on the right side with hilar haze. A provisional diagnosis of HAPE was made with the differential diagnosis of coronavirus disease 2019 (Covid-19) pneumonia. He was managed on the line of HAPE. The next day, his nasopharyngeal swab for Covid-19 reverse transcription-PCR (RT-PCR) test turned out to be positive, but his general condition had markedly improved maintaining a SpO2 of 93% on 2-3 L/min and RR of 18/min. Repeat chest radiograph on Day 4 was within normal. He got discharged from the hospital on Day 22 of admission after a nasopharyngeal swab for RT-PCR turned out to be negative.