Abstract
BackgroundThere are various reasons for delayed positive nasopharyngeal PCR tests for coronavirus disease 2019 (COVID19) in not only asymptomatic but also severely diseased patients. The pathophysiological attributes are not known. We explore this possibility through a case report.Case presentationA 64-year-old male with history of pulmonary fungal infection, asthma and chronic pulmonary obstructive disease (COPD), diabetes, coronary artery disease presented with shortness of breath, fever and chest image of ground opacity, reticular interstitial thickening, highly suspicious for COVID19. However, nasopharyngeal swab tests were discordantly negative for four times in two weeks, and IgG antibody for COVID19 was also negative. However, serum IgE level was elevated. No other pathogens are identified. His symptoms deteriorated despite corticosteroid, antibiotics and bronchodilator treatment. Bronchoalveolar lavage (BAL) and open lung wedge biopsy were performed for etiology diagnosis. They demonstrated COVID19 viral RNA positive fibrosing organizing pneumonia with respiratory tract damage characterized by suspicious viral cytopathic effect, mixed neutrophilic, lymphoplasmacytic, histiocytic and eosinophilic inflammation and fibrosis besides expected asthma and COPD change. One week later, repeated COVID19 nasopharyngeal tests on day 40 and day 49 became positive.ConclusionOur case and literature review indicate that allergic asthma and associated high IgE level together with corticosteroid inhalation might contribute to the delayed positive nasopharyngeal swab in upper airway; COPD related chronic airways obstruction and the addition of fibrosis induced ventilator dependence and poor prognosis in COVID19 pneumonia, and should be therapeutically targeted besides antiviral therapy.
Highlights
There are various reasons for delayed positive nasopharyngeal PCR tests for coronavirus disease 2019 (COVID19) in asymptomatic and severely diseased patients
Our case and literature review indicate that allergic asthma and associated high IgE level together with corticosteroid inhalation might contribute to the delayed positive nasopharyngeal swab in upper airway; chronic pulmonary obstructive disease (COPD) related chronic airways obstruction and the addition of fibrosis induced ventilator dependence and poor prognosis in COVID19 pneumonia, and should be therapeutically targeted besides antiviral therapy
Bronchoalveolar lavage showing (a) neutrophilic predominant inflammation mixed with some eosinophils, and (b) reactive pneumocytes with suspicious viral cytopathic effect; (c–h) lung wedge biopsy revealing asthma change with thickened bronchiolar wall (c, left) and mucus plug (c, upper right), and COPD which is characterized by emphysema with dilated alveoli distal to bronchiole without fibrosis (c, right) and squamous metaplasia reparative to chronic damage (c, left lower), as well as newly onset active pneumonia with alveolar and interstitial fibrosis (c, mid), type II pneumocytes with possible viral cytopathic effect (d), acute pneumonia with alveolar damage (e), alveolar edematous exudate, intraalveolar fibrosis (f), rare syncytial cells amid squamous metaplasia (g), and endothelial injury (h)
Summary
Recognition of differential susceptibility in association with various preexistent diseases can help prevent erroneously ruling out COVID-19 based on false-negative diagnostic tests. Our case and literature review indicate that: (1) Allergic asthma and associated high IgE level together with corticosteroid inhalation might contribute to the delayed positive nasopharyngeal swab in upper airway. (2) COPD related chronic airways obstruction and the addition of fibrosis induced ventilator dependence and poor prognosis in COVID19 pneumonia, and should be therapeutically targeted besides antiviral therapy. Abbreviations COVID19: Coronavirus disease 2019; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; RT-PCR: Reverse transcriptase polymerase chain reaction; COPD: Chronic pulmonary obstructive disease; CT: Computed tomography; BAL: Bronchoalveolar lavage; CPAP: Continuous positive airway pressure; PEEP: Positive end-expiratory pressure; ACE2: Angiotensin-converting enzyme 2; TMPRSS2: Transmembrane serine protease 2
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