Abstract
The British Society of Thoracic Imaging (BSTI) has published clear guidance on the classification of chest X-ray (CXR) findings in coronavirus disease 2019 (COVID-19) patients, which are summarised in four main categories: COVID-classical, COVID-indeterminate, COVID-normal, or non-COVID. We report the case of a 34-year-old lady who is otherwise fit and well. She presented with typical COVID-19 symptoms requiring supplemental oxygen, with normal CXR and COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) swab on admission. Her condition deteriorated after 24 hours with severe hypoxia requiring up to 60% oxygen. Repeat CXR was normal, which was followed by computed tomography pulmonary angiogram (CTPA) that ruled out pulmonary embolism; however, CTPA confirmed multi-lobar pneumonia consistent with COVID-19. The patient was admitted to the intensive care unit for non-invasive ventilation (NIV) and ongoing care. Extended respiratory screening confirmed positive COVID-19 antibodies and positive adenovirus swabs. The patient also developed COVID-19 related hepatocellular injury and myocarditis in the absence of other causes. These were treated by a multidisciplinary team, and the patient achieved full recovery after three weeks. This case highlights the fact that normal CXR does not rule out COVID-19 pneumonia even in the severely hypoxic patient requiring NIV. Also, it is important to investigate for other potential causes of hypoxia in a deteriorating patient, such as pulmonary embolism and non-COVID causes of pneumonia.
Highlights
The novel coronavirus disease 2019 (COVID-19), known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an enveloped, non-segmented positive-sense RNA virus belonging to the beta-Coronaviridae family [1]
The British Society of Thoracic Imaging (BSTI) has published clear guidance on the classification of chest Xray (CXR) findings in COVID-19 patients, which are summarized in four main categories: COVID-classical, COVIDindeterminate, COVID-normal, or non-COVID
There are no clear explanations from this group of patients that any case with a normal CXR was severely hypoxic requiring non-invasive ventilation, similar to what happened with our patient
Summary
The novel coronavirus disease 2019 (COVID-19), known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an enveloped, non-segmented positive-sense RNA virus belonging to the beta-Coronaviridae family [1]. Her airway was patent, chest examination revealed normal breathing sounds bilaterally, and otherwise there were no stigmata of chronic respiratory disease clinically. The patient was treated as a suspected case of COVID-19 with a potentially associated lower respiratory tract infection She was started on intravenous antibiotics (clarithromycin), intravenous dexamethasone 6 mg once a day, intravenous fluids for rehydration, and low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis. Around 24 hours into her admission, the patient started to deteriorate with respiratory distress and requiring up to 60% of oxygen through a face mask to maintain her peripheral saturation as 98% Her blood pressure and heart rate were normal at that time.
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