Unilateral diaphragm paralysis with COVID-19 infection
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Lower respiratory tract involvement is a common feature of infection with the SARS-CoV-2 virus, most notably respiratory failure due to viral pneumonitis, but as the COVID-19 pandemic continues, long-term complications are emerging. Among these are involvement of the neurological tract and chronic lung disease, chiefly pulmonary fibrosis. Researchers report a case of unilateral diaphragmatic paralysis in an individual with SARS-CoV-2 infection, and explore the possible contributory factors and learning points of this novel case.

A 54-year-old Caucasian man was admitted with rapidly progressive dyspnoea due to PCR positive SARS-CoV-2 infection. He had a history of insulin dependent type 2 diabetes mellitus, obstructive sleep apnoea (OSA) managed with home continuous positive airway pressure (CPAP), primary hypertension and a raised body mass index (38.1 kg/m2). He reported no other respiratory history and was a non-smoker.

After 3?days, due to refractory type 2 respiratory failure despite CPAP, he was intubated and placed on lung protective airway pressure release ventilation with intense neuromuscular blockade. He also developed acute renal failure, for which he received temporary veno-venous renal replacement therapy. Standard drug treatment in use for SARS-CoV-2 pneumonia at the authors’ unit at the time was given: intravenous broad-spectrum antibiotics, anticoagulation and corticosteroids.

The initial chest radiograph showed ground glass consolidation in the left lung, with normal bilateral haemidiaphragm position, but this progressed rapidly to bilateral, peripherally predominant ground glass change consistent with SARS-CoV-2 pneumonia. Bilateral consolidation and volume loss were seen early in the admission, with a progressively elevated right haemidiaphragm from day 7.

He had received a right jugular central venous catheter (CVC) at the beginning of his admission, but this was placed without complication, replaced soon after by a contralateral jugular haemofiltration line and the elevated right haemidiaphragm did not become apparent for 4?days after placement. A tracheostomy was performed at 2 weeks, followed by a prolonged respiratory wean supported with CPAP, and he was liberated from mechanical ventilator support after 37 days.

No iatrogenic injury to the neck was noted during this period. CT thorax at this point showed bilateral multifocal consolidation worse on the right, with an elevated right haemidiaphragm.

Following a period of rehabilitation, he was discharged at 61 days. At 4-month clinic review, he reported persistent dyspnoea and orthopnoea. CT revealed significant improvement of the consolidation, with a raised right haemidiaphragm and minor residual upper lobe linear atelectasis.

His symptoms persisted, and at 9 months dynamic chest radiography (a real-time large-field-of-view thoracic imaging system) demonstrated clear lung fields but a raised right haemidiaphragm with ipsilateral paradoxical motion on sniff manoeuvre. Spirometry showed a postural reduction in forced vital capacity of 43.5% from standing to lying. He subsequently underwent surgical plication.

Source: https://casereports.bmj.com/content/14/6/e243115?rss=1
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