Case Study: Previously Hospitalized COVID-19 Patient Returns to the ED

Posted in: Announcements, Blog, COVID-19, Ultrasound Literature|May 11, 2020

This elderly female was brought in by EMS due to anemia. She was hemodynamically stable but had a hemoglobin of 6 g/dL detected during a routine outpatient laboratory assessment. She reported having a transfusion-dependent myelophthisic anemia.

This patient was initially diagnosed with COVID-19 four weeks ago. She was hospitalized for two weeks due to pneumonia and was treated with remdesivir. She was discharged to a skilled nursing facility and had been there for the last 14 days.

She denied recent fevers but did report a mild cough and persistent fatigue. Physical exam revealed an elderly female in no distress with a T=37 C, O2 sat=94% on room air, RR=18, HR=80, and BP=140/90 mmHg. Physical exam was unremarkable, including normal heart and lung exams.

Lung Ultrasound

Bilateral lung ultrasound demonstrated focal pleural irregularities, focal subpleural consolidations, and scattered B-lines.

Laboratory Findings

Repeat hemoglobin in the ED was 5.8 g/dL. A repeat COVID-19 PCR test returned positive. Her serum LDH level was elevated at 493 U/L and serum ferritin elevated at 3,248 ng/mL.

Initial Management

The patient underwent transfusion of two units of packed PRBCs. Bedside lung ultrasound findings included pleural irregularities, focal subpleural consolidations, and a shred or fractal sign. Scattered, non-specific B-lines were also noted. A repeat COVID-19 PCR test was positive. A chest x-ray taken during her prior, initial COVID-19 diagnosis and hospitalization is shown below.

This CXR was taken three weeks earlier during her initial COVID-19 hospitalization and revealed bilateral mild, diffuse increased markings with localized increase in density in the right lower lobe.

Patient Disposition & Hospital Course

This patient was admitted to a monitored bed under enhanced droplet and contact precautions with a diagnosis of myelophthisic anemia and subacute COVID-19 infection. The enhanced droplet and contact precautions were instituted due to a concern that the patient’s underlying immunodeficiency syndrome may lead to a protracted period of SARS-CoV-2 transmission risk.

Integrating Ultrasound Findings into Medical Decision-Making

The patient was originally diagnosed with COVID-19 four weeks earlier and was minimally symptomatic prior to this most recent hospitalization for an unrelated anemia. How should this patient’s lung ultrasound and COVID-19 PCR results be integrated into clinical decision-making? Was this patient still capable of transmitting SARS-CoV-2 to others?

How long does it take for lung ultrasound findings to resolve following clinical recovery from COVID-19?

At present, there is insufficient published literature to precisely map evolution of lung ultrasound findings relative to clinical recovery. However, some general patterns are emerging (see Table 1). Lung ultrasound has been shown to be an effective method for detecting and monitoring disease progression (Benchoufi et al., Rubin et al., Soldati et al.).

Buonsenso et al. described the temporal resolution of pathologic lung ultrasound findings in a small series of pregnant COVID-19 positive patients as they recovered from illness. Sonographic findings of lung consolidation resolved as patients recovered. Subsequently, multiple and/or confluent B-lines became less frequent and evolved into scattered B-lines. Finally, B-lines became uncommon and a normal A-line pattern returned (Buonsenso et al.).

Buonsenso D, Raffaelli F, Tamburrini E, et al. Clinical role of lung ultrasound for the diagnosis and monitoring of COVID‐19 pneumonia in pregnant women. Ultrasound Obstet Gynecol. 2020 Apr 26. doi: 10.1002/uog.22055. [Epub ahead of print]

Soldati G, Smargiassi A, Inchingolo R, et al. Is there a role for lung ultrasound during the COVID-19 pandemic? J Ultrasound Med. 2020 Mar 20. doi: 10.1002/jum.15284. [Epub ahead of print]

Does a positive COVID-19 PCR test always equate with the ability to transmit infection?

Symptomatic patients with a positive COVID-19 PCR test result are presumed capable of transmitting infection to others. In response to the aforementioned question, the CDC states “detecting viral RNA via PCR does not necessarily always mean that infectious virus is present.” The CDC also states “there have been reports of prolonged detection of RNA without direct correlation to viral culture.” Hence, the CDC advocates for a symptom-based or test-based strategy for assessing SARS-CoV-2 transmission risk and discontinuation of transmission precautions in originally symptomatic patients with confirmed COVID-19 (see Table 2).

The current gold standard for diagnosis of COVID-19 infection is SARS-CoV-2 nucleic acid detection using real-time, reverse transcriptase-polymerase chain reaction (rRT-PCR) assay. Given that this testing method involves nucleic acid extraction, reverse transcription into complementary DNA (cDNA), and subsequent amplification, occasional false-negative and false-positive results may occur (Ai et al., Fang et al., Lu et al.).

False-negative results have been attributed to operator-dependent nasal sample collection, patients with low viral loads, and RNA degradation during specimen processing (Lu et al.). Hence, negative results do not definitively exclude SARS-CoV-2 infection and should not be the sole basis for making patient management decisions. False-positive results are more likely to be noted when disease prevalence is lower.

*Consider consulting with local infectious disease experts when making decisions about discontinuing transmission-based precautions for patients who might remain infectious longer than 10 days (e.g., severely immunocompromised).

Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance) [Internet]. 2020 [cited 2020 May 5]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html

Key Points

Focal subpleural consolidation with adjacent overlying pleural thickening, pleural line discontinuity, and B-lines are consistent with COVID-19 infection.
The precise duration of time required for resolution of sonographic lung findings following COVID-19 clinical recovery is unclear.
The CDC advocates for a symptom-based or test-based strategy for discontinuation of transmission precautions in initially symptomatic patients with confirmed COVID-19 infection.
The precise duration COVID-19 patients may transmit infection following clinical recovery remains a topic of active investigation.

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]

Benchoufi M, Bokobza J, Chauvin AA, et al. Lung injury in patients with or suspected COVID-19: a comparison between lung ultrasound and chest CT-scanner severity assessments, an observational study. MedRxiv 2020.04.24.20069633 [Preprint]. 2020 [cited 2020 May 5]. Available from: https://doi.org/10.1101/2020.04.24.20069633

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]

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

Rubin GD, Ryerson CJ, Haramati LB, et al. The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society. Chest. 2020 Apr 7. pii: S0012-3692(20)30673-5. doi: 10.1016/j.chest.2020.04.003. [Epub ahead of print]

Soldati G, Smargiassi A, Inchingolo R, et al. Is there a role for lung ultrasound during the COVID-19 pandemic? J Ultrasound Med. 2020 Mar 20. doi: 10.1002/jum.15284. [Epub ahead of print]

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