NOT EVERYTHING IS COVID: PERSISTENT FEVER AND MALAISE MIMICKING COVID-19 PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The diagnosis of COVID-19 has depended on the use of a Reverse transcriptase polymerase chase reaction test (RT-PCR) on respiratory samples. While this has directed the response and care of patients with suspected COVID-19, there have been false-negative results depending on when the test was administered in relation to time of exposure and symptom onset. CASE PRESENTATION: A 19-year-old male with no significant past medical history presented to the emergency department in July 2020 with a persistent fever of 100 -103F for 10 days. He returned from Texas 9 days prior with onset of fever one day before depature. He had a mild, non-productive cough, body aches, and poor oral intake. He also had diffuse abdominal pain with diarrhea and bilious, non-bloody vomiting - up to three times a day. He had elevated WBC, ESR, CRP and LDH with Lymphopenia. Blood cultures and HIV, Syphilis, EBV and Mycoplasma screening were negative as was a COVID-19 test. CT scan of his chest and abdomen revealed peripheral ground glass opacities suspicious of COVID 19. A repeat COVID test on hospital day 2 was again negative. He was treated with Azithromycin and Doxycycline and discharged home on Azithromycin on hospital day 4. He was readmitted 6 days later because of persistent fever to 103F, joint pains, malaise and weight loss of about 10 pounds. ESR, CRP, Ferritin and LDH were again elevated. A repeat CT scan showed resolution of previously seen ground glass opacities in the anterior lung fields and new confluent areas of ground glass attenuation and interlobular septal thickening posteriorly. A 3rd, 4th and 5th COVID-19 tests performed were negative. He was treated with Acetaminophen alternating with Ketorolac. A TTE showed a hyperlucency concerning for a right atrial thrombus or vegetation. Left ventricular ejection fraction was 50%. An MRI of the heart showed an inflammatory picture consistent with myocarditis. Further testing was done to reveal the etiology of his myocarditis to be Coxsackie A7,9, and 16. Clinically, there was significant improvement with resolution of fever and malaise and return of WBC count to normal. DISCUSSION: This patient's diagnosis of Coxsackie A myocarditis was clouded by the medical team's strong suspicion of COVID-19 pneumonia because of his clinical presentation and history of travel during the month of June to a part of the US with rising rates of COVID-19 cases. The unknown precise false-negative rate of the COVID-19 test, which can be anywhere from 2-27% depending on the time of testing from initial exposure meant that the diagnosis was never deemed impossible even with consecutive negative test results. CONCLUSIONS: While the attention COVID-19 is receiving is well deserved, anecdotal accumulation of evidence along with the scientific community's first wave of research has produced heuristics that need to be overcome to optimize patient care and outcomes. REFERENCE #1: Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Lessler J. Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction–Based SARS-CoV-2 Tests by Time Since Exposure. Ann Intern Med [Internet]. 2020 May 13 REFERENCE #2: Arevalo-Rodriguez I, Arevalo-Rodriguez I, Buitrago-Garcia D, Simancas-Racines D, et al. False-negative results of initial RT-PCR assays for COVID-19: a systematic review. April 21, 2020 (preprint). REFERENCE #3: Steven Woloshin, M.D., Neeraj Patel, B.A., and Aaron S. Kesselheim, M.D., J.D., M.P.H. False Negative Tests for SARS-CoV-2 Infection — Challenges and Implications. DOI:10.1056/NEJMp2015897, June 5, 2020 DISCLOSURES: No relevant relationships by Christiana Atuaka, source=Web Response No relevant relationships by Carmina Aybar Rodriguez, source=Web Response No relevant relationships by Claudia De Araujo Duarte, source=Web Response No relevant relationships by Khurriyat Foziljonova, source=Web Response No relevant relationships by Varun tej Gonuguntla, source=Web Response No relevant relationships by Margaret Ku n-Basti, source=Web Response