#OxfordClinicalCases: COVID-19 infection presenting with acu
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A 60-year-old obese male, BMI 45.78 kg/m2, with a past medical history of well-controlled hypertension presented to the emergency department with acute dysphagia, hoarseness of voice, shortness of breath, and stridor. He was in his normal state of health until that morning when he was awoken by a sore throat and difficulty breathing. On presentation, the patient’s temperature was 37.2°C, blood pressure 152/94 mm Hg, heart rate 133 beats per minute, respiratory rate 28 breaths per minute, and oxygen saturation 93% while the patient was breathing ambient air. He was observed to be in mild respiratory distress and sitting upright for comfort. His posterior oropharynx was erythematous with enlarged tonsils which prompted immediate imaging.

The chest X-ray showed minimal blunting of the left costophrenic angle. Computed tomography soft tissue neck with IV contrast revealed a nearly complete airway obstruction due to marked epiglottic enlargement and pre-epiglottic edema consistent with epiglottitis. Intubation was unsuccessfully attempted, limited by the severely erythematous, friable and purulent epiglottis. He promptly underwent an emergency cricothyroidotomy and was transferred to the intensive care unit where he was started on empiric ampicillin–sulbactam and azithromycin.

On Day 1 after admission, the initial COVID-19 high-sensitivity PCR nasopharyngeal swab came back as negative. However, postoperatively, high positive end expiratory pressure of 14 mmHg on mechanical ventilation was noted, and this combined with his repeat CXR (Fig. 1B) was suspicious of COVID-19 infection. This prompted a repeat test, which on Day 2 was COVID-19 high-sensitivity PCR positive. On Day 3, the cricothyrotomy was surgically converted to a tracheostomy, and on Day 7 he was successfully weaned off the ventilator, with completion of antibiotics and continued progress.

Source: https://academic.oup.com/jscr/article/2020/9/rjaa280/5902509
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