Introduction and expectation from this blog :
1 .In this e-log I shall document about a 67 year old lady who presented with cough since 7 days , Fever since 6 days and present oxygen saturation of 85-88 percent on room air.
2. I shall also elaborate upon the course of her disease from before her presentation to the hospital till date.
3.Since it is an ongoing pandemic, where, till now studies are on about the order of events which are occuring in the disease and the time line is of great value,
I shall describe the progression of the disease under the heading of the respective "Day" on which the patient got the symptoms.
4.A note shall also be mentioned about the contact tracing regarding the source of the infection.
Note on De identification :
All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
TIMELINE :
26 April 2021
The domestic help at the patient's house was having mild fever .( came to the knowledge of the patient's family later )
28.April.2021
The 67 year old developed dry cough .
29.April.2021
She began having low grade fever ( 99 deg. Cel. ) with body ache, also she felt very weak and stayed in her bed all day long.
Nasopharyngeal swab sample given for RT PCR.
30th April 2021 to 3rd May 2021
RT PCR report : Positive
High grade fever ( 102.5 deg. Cel. )
Loss of taste
Loss of appetite.
Cough with sputum ( sputum white in colour, thick in consistency , non foul smelling )
Blood sample collected on 1st May 2021 for serum markers.
Reports :
3rd May 2021 ( evening )
The patient's son took her to a fever clinic and got a HRCT chest done whereby the CT index was 12/25
CT report :
3rd May 2021 ( night )
Oxygen Saturation kept falling and reached about 88 percent on r.a.
4th May 2021
Patient presented to Hospital
Admitted in the COVID ward.
Upon presentation ,she had Spo2 of 85 percent on room air .
VITALS UPON PRESENTATION
PR 80 bpm,
BP 110/80mm hg
RR : 22 cpm
Body Temperature : Febrile
GRBS 130 mg/dl
SpO2 85% with r.a
Other existing pathologies in the patient :
Hypothyroidism since the last 20 years and is on Levo thyroxine supplements
She is also a known case of hypertension for the past 20 years and takes antihypertensives.
Central Obesity present.
Interventions done :
O2 inhalation
15 litres/minute ( wherein Spo2 rose to 90% )
On presentation : Inj. Dexamethasone 8 mg
Injection clexane 40 mg ( subcutaneous )
Hrct done.
Other interventions,
Tab. Pcm
Tab pantop
Tab. Eltroxin 75mg of
Tab. Olmesartan 40mg od
Tab. Met xl 12.5mg of
Tab. Clinidipine 10mg od
Nebulization with duolin and budecort
Tab. Ecosprin 75mg of
Tab. Atorvas
Inj. Clexane 40mg od
Inj.Dexamethasone 8mg od
( Timeline Continued )
6th may 2021
Modification of O2 delivery : Reduced to 10 litres per minute
whereby her Spo2 was maintaining at 94 percent.
Other medications continuing as before.
10th May 2021
Spo2 maintained at 93 percent at 10 litres per minute.
The patient spoke irrelevantly to her attending doctor , called her son at midnight complaining of somebody waiting near her bed to kill her or take her away by morning.
( C.C. televisions were checked that there was nobody of such description at that time of the night )
11th May 2021
Patient hypersomnolent.
Appears more like a stupor.
Still talks irrelevant.
PR 76
SpO2 95% with 10lit of O2
Spo2 80% at room air
Psychiatry referral taken in view of ICU psychosis.
INVESTIGATION VALUES
Sample taken on (6/5/2021)
Crp: 4.8ng/ml
Ddimer :420ng/ml
Hb: 12.2gm%
Platelet count : 1.5lakh/mm3
Sample taken on (9/5/2021)
Crp: 4.8mg/dl
Ddimer :420ng/ml
Plt count :3.10 lakhs/cumm
Medications added after the Psychiatry Consult :
Tab. Piracetam 400mg od
Syp.Resperidone 0.25ml HS
Other medications continued as before.
Attempts made to reduce flow rate of oxygen delivery based on improvement.
She is maintaining Spo2 of 95 % at flow rate of 6 litres per minute.
Medications being administered :
Tab. Pcm
Tab pantop
Tab. Eltroxin 75micrograms OD
Tab. Olmesartan 40mg od
Tab. Met xl 12.5mg of
Tab. Cilnidipine 10mg od
Nebulization duolin and budecort
Tab. Ecosprin 75mg of
Tab. Atorvas 10mg
Tab. Piracitam 400mg od
Syp.Resperidone 0.25ml HS
Inj. Clexane 40mg od
Dexamethasone 8mg od
Rationale of using Piracetam in this patient :
Piracetam , under pharmacological classification falls under Nootropics with properties of memory and cognitive enhancement .
It is said to improve mood and motivate the mind.
Being a derivative of Gamma aminobutyric acid , it modulates neurotramission in a range of transmitter systems ( proportion of GABAergic and cholinergic tranmission )
It has neuroprotective and anticonvulsant properties
It enhances neuroplasticity
Reference Reading :
https://pubmed.ncbi.nlm.nih.gov/16007238/
https://www.icudelirium.org/medical-professionals/delirium/management-of-delirium-in-the-icu
https://pubs.asahq.org/anesthesiology/article/125/6/1229/18605/Intensive-Care-Unit-DeliriumA-Review-of-Diagnosis
Concerned Reports and Cross Consultations :
Notes by the Department of Psychiatry :
PERSONAL HISTORY :
67 year old Lady
Known Case of : Hypertension , Hypothyroidism ( under medication for both)
Central Obesity.
Viral Pneumonia Secondary to COVID
Probably suffering from ICU Psychosis.
DISCUSSION :
This case was posted ( after adequate de-identification ) on online portals which led to a discussion about the same . A section of it has been shared below-
(GM : Group Member )
Moderator: The 67F was having hypersomnolence in the day time during yesterday's morning rounds.
Later her attender told me she had phoned them at 3:00 AM yesterday complaining that there was a man here who was threatening to take her away by morning. We checked the CCTV footage during that time yesterday and didn't find anyone near her bed except she did appear to wake up sometime around that time and was on the phone.
I later realized she was talking a bit irrelevantly when I met her yesterday when i assumed was in her sleep like stupor.
What do you think is happening to her in terms of differential diagnosis of a woman with covid pneumonia and sudden altered behaviour?
GM1: this kind of presentation may be due to hypothyroidism
GM2: could it be delirium?
GM3: Encephalitis/encephalopathy as a complication of COVID?
GM4: Suboptimal carbon dioxide washout maybe leading to somnolence..
And the deranged conversations maybe cause of her hospital stay? ..
Or electrolyte imbalance..
GM5: did she have any history of dementia prior to being diagnosed with COVID
GM6: could the virus directly affect leading to psychosis or indirectly due to overstimulation of the immune system?
GM7:
Can it be a sign of deterioration
Increased demand in the infection vs reduced thyroid harmones in the context of preexisting hypothyroidism
GM8: could it be due to Obstructive sleep Apnoea? As they can be at a risk of psychosis and hypoxic encephalopathy
GM9: it could be due to decreased oxygen supply to brain
GM9: Also CVA ( stroke)
GM10: An embolism or blood clot in brain, precipitated by infection? (She has history of CVA)
GM11: it may be a hallucination?
GM12: Neurotropic(coronavirus)?
GM13: Cytokine storm induced inflammation leading to delirium? (Since she isn't on tocilizumab/siltuximab )
GM14 : could it be schizophrenia from any immune mediated activation due to a profound inflammatory response from the Covid infection?
Moderator : please share some more details about her history of hypothyroidism with particular reference to drug dosage and control over the last few years
Moderator: Please share some literature around it
Moderator: Very interesting answer with three intriguing angles
Suboptimal CO2 washout would be also known as hypoventilation. This brings up another learning question around covid pneumonia:
Why do covid patients often require ventilation?
Is it due to hypoventilation or hypoxia? What are the causes of hypoventilation?
Moderator: Second point related to her hospital stay? Please elaborate
Moderator: check out her electrolytes shared earlier above
Moderator: Share some literature (similar reports )to support your hypothesis
Moderator: Join the dots between your causal hypothesis and brain function
Moderator: Good point. What are the clinical criteria we can use to diagnose obstructive sleep apnoea in her?
Moderator: What is the most important clinical criteria to diagnose a stroke?
GM15: is it possible that she was dreaming about the man as the cctv evidence suggests of intermittent sleep and there can be REM sleep where most of the dreams seem to he so real.
and also association with the fear and hysteria around she could be talking a bit irrelevant. Considering her age and possibly rural background toddy(impure or the synthetic one) withdrawal can also cause such symptoms.
GM16: Here is a cohort analysis of delirium and encephalopathy in severe covid 19 patients. 140 Covid ICU patients were included in the study. Neurological examination was normal in 22 patients. 118 patients developed delirium with a combination of acute attention, awareness, and cognition disturbances. 88 patients presented an unexpected state of agitation despite high infusion rates of sedative treatments and neuroleptics, and 89 patients had corticospinal tract signs.
Results and conclusion : "The delirium/neurological symptoms in COVID-19 patients were responsible for longer mechanical ventilation compared to the patients without delirium/neurological symptoms. Delirium/neurological symptoms could be secondary to systemic inflammatory reaction to SARS - Cov 2 "
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03200-1
[1:52 PM, 5/16/2021] Saranya: According to this study, 3 triggers may be responsible for the delirium seen in covid patients :
(1) hypoxia and oxygen deficiency of
the brain
(2) neuronal inflammation due to cytokine storm as a result
of a strong activation of the immune system
(3) direct CNS
invasion and neuronal toxicity
Moderator : GM15 is right about that possibility as well as the other differentials shared here as past cases reported by others.
We are currently keeping a provisional diagnosis of ICU psychosis and have put her on a low dose of antipsychotic.
Today morning she looked much better and we are even planning to try out home oxygenation supported by oxygen concentrators and venti masks along with regular SpO2 monitoring and sharing with our group here.
They are planning to keep her in a room in hotel for a few days so that we can keep reviewing her in OPD once in a while.
She's not out of the woods and may even worsen but we feel she may have a better emotionally supporting environment with home care.
Let's see what happens to her over the next two days before we think of discharging from the ICU.
NOTE : Any further inputs,comments regarding the case are welcome.
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