Case Study: COVID-19 Rule-Out Patient Presenting with Gastrointestinal Symptoms & Dyspnea

This young adult female presents complaining of progressive dyspnea on exertion and generalized weakness. She reports several days of nausea, vomiting, and diarrhea one week prior to onset of dyspnea.

The patient lives in a region with a moderate prevalence of COVID-19 but has not had known direct contact with a COVID-positive patient. She has an unremarkable physical exam. The patient is triaged as a rule-out COVID-19 patient based on presenting complaints.

Lung Ultrasound

Lung ultrasound revealed focal areas of pleural discontinuity and focal subpleural consolidations, displaying a “shred or fractal” sign (Biswas et al., Lichtenstein et al.). These findings are consistent with viral pneumonia and have also recently been described in COVID-19 patients (Chung et al., Huang et al., Peng et al.).

Limited Echo Findings

Limited echo findings included normal LV size with severely reduced LVEF, measuring approximately 25%. Normal RV chamber size and function. Small pericardial effusion present. The IVC measured > 2.1 cm and displayed ≤ 50% respirophasic collapse, consistent with an RAP of 15 to 20 mmHg. No end-diastolic RV collapse was noted. There was < 25% respirophasic variation in mitral valve inflow velocity. Reviewing all the echocardiographic findings together, there was insufficient evidence to suggest cardiac tamponade physiology.

 Integrating Ultrasound Findings into Medical Decision Making

This patient presented with a history of gastrointestinal symptoms followed by cardiopulmonary symptoms, which is compatible with COVID-19, among other illnesses. She had lung findings suggestive of a viral pneumonia and echocardiographic evidence of an acute cardiomyopathy likely resulting from myopericarditis. She was admitted with enhanced droplet precautions to a monitored bed and underwent COVID-19 testing while receiving supportive care.

Her initial troponin value was normal, BNP was mildly elevated (126 pg/mL), AST (27 U/L) and ALT (28 U/L) values were normal, and a mild leukocytosis with an absence of lymphopenia was noted. Urinalysis revealed 3+ nephrotic range proteinuria. The patient was scheduled for renal biopsy. Differential diagnosis for acute myopericarditis and nephrotic-range proteinuria includes an autoimmune condition, systemic viral infection, primary glomerulonephropathy, systemic infiltrative disorder (e.g., amyloidosis), or a combination of the above.

Importantly, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid detection by PCR testing is the most widely used method for COVID-19 diagnosis. There are widespread reports of high rates of false-negative PCR test results (Ai et al., Fang et al., Lu et al.). These inconsistencies have been attributed to operator-dependent nasal sample collection, patients with low viral loads, and RNA degradation during specimen processing.

Key Points

• Non-specific lung ultrasound findings in patients with COVID-19 infections include pleural thickening and irregularity, focal and diffuse B-lines, consolidations, and pleural effusions (Huang et al., Peng et al.).
• Differentiating viral versus bacterial etiologies of pneumonia exclusively based upon radiographic findings is difficult (Korppi et al., Nambu et al.). However, solitary lobar, segmental, or round consolidations are more suggestive of bacterial pneumonias, while viral pneumonias more often display diffuse, bilateral interstitial findings (Berce et al., Biswas et al.).
• COVID-19 patients may present with symptoms resulting from cardiac involvement, including acute-onset heart failure, myocardial infarction, myocarditis, and cardiac arrest (Arentz et al., Clerkin et al., Huang et al.).
• Two important applications of ultrasound in COVID-positive or rule-out COVID patients is (1) to screen for characteristic COVID-19 ultrasound findings and (2) to seek to identify alternative etiologies for patients’ symptoms.
• Clinicians face the added current challenge of not having highly reliable methods for definitively excluding SARS-CoV-2 infection (i.e., false-negative PCR test results).
• If clinical signs and symptoms are highly suggestive of COVID-19 infection and an alternative etiology has not been definitively established, continuing to maintain patients on enhanced droplet precautions and performing repeat testing is prudent.

Ai T, Yang Z, Hou H, et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology. 2020 Feb 26:200642. doi: 10.1148/radiol.2020200642. [Epub ahead of print]

Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 2020 Mar 19. doi: 10.1001/jama.2020.4326. [Epub ahead of print]

Berce V, Tomazin M, Gorenjak M, et al. The usefulness of lung ultrasound for the aetiological diagnosis of community-acquired pneumonia in children. Sci Rep. 2019 Nov 29;9(1):17957. doi: 10.1038/s41598-019-54499-y.

Biswas A, Lascano JE, Mehta HJ, et al. the utility of the “shred sign” in the diagnosis of acute respiratory distress syndrome resulting from multifocal pneumonia. Am J Respir Crit Care Med. 2017 Jan 15;195(2):e20-e22. doi: 10.1164/rccm.201608-1671IM.

Chung M, Bernheim A, Mei X, et al. CT imaging features of 2019 novel Coronavirus (2019-nCoV). Radiology. 2020 Apr;295(1):202-207. doi: 10.1148/radiol.2020200230. Epub 2020 Feb 4.

Clerkin KJ, Fried JA, Raikhelkar J, et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation. 2020 Mar 21. doi: 10.1161/CIRCULATIONAHA.120.046941. [Epub ahead of print]

Fang Y, Zhang H, Xie J, et al. Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiology. 2020 Feb 19:200432. doi: 10.1148/radiol.2020200432. [Epub ahead of print]

Huang Y, Wang S, Liu Y, et al. A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19). [Preprint]. 2020 [cited 2020 Mar 23]: [14 p.]. Available from: https://ssrn.com/abstract=3544750 or http://dx.doi.org/10.2139/ssrn.3544750

Korppi M, Kiekara O, Heiskanen-Kosma T, et al. Comparison of radiological findings and microbial aetiology of childhood pneumonia. Acta Paediatr. 1993 Apr;82(4):360-363.

Lichtenstein DA, Lascols N, Mezière G, et al. Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med. 2004 Feb;30(2):276-281. doi: 10.1007/s00134-003-2075-6. Epub 2004 Jan 13.

Lu R, Wang J, Li M, et al. SARS-CoV-2 detection using digital PCR for COVID-19 diagnosis, treatment monitoring and criteria for discharge. MedRxiv 2020.03.24.20042689 [Preprint]. 2020 [cited 2020 Apr 16]. Available from: https://www.medrxiv.org/content/10.1101/2020.03.24.20042689v1 doi: https://doi.org/10.1101/2020.03.24.20042689

Nambu A, Ozawa K, Kobayashi N, Tago M. Imaging of community-acquired pneumonia: Roles of imaging examinations, imaging diagnosis of specific pathogens and discrimination from noninfectious diseases. World J Radiol. 2014;6(10):779-793. doi:10.4329/wjr.v6.i10.779

Peng, QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med. 2020 Mar: 1-2. doi: 10.1007/s00134-020-05996-6. [Epub ahead of print]

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