A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease

Abstract

Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease with an alarming case fatality rate up to 5%. The risk factors for severe presentations are concentrated in patients with chronic kidney disease, particularly patients with end-stage renal disease (ESRD) who are dialysis dependent. We report the first US case of a 56-year-old nondiabetic male with ESRD secondary to IgA nephropathy undergoing thrice-weekly maintenance hemodialysis for 3 years, who developed COVID-19 infection. He has hypertension controlled with angiotensin receptor blocker losartan 100 mg/day and coronary artery disease status-post stent placement. During the first 5 days of his febrile disease, he presented to an urgent care, 3 emergency rooms, 1 cardiology clinic, and 2 dialysis centers in California and Utah. During this interval, he reported nausea, vomiting, diarrhea, and low-grade fevers but was not suspected of COVID-19 infection until he developed respiratory symptoms and was admitted to the hospital. Imaging studies upon admission were consistent with bilateral interstitial pneumonia. He was placed in droplet-eye precautions while awaiting COVID-19 test results. Within the first 24 h, he deteriorated quickly and developed acute respiratory distress syndrome (ARDS), requiring intubation and increasing respiratory support. Losartan was withheld due to hypotension and septic shock. COVID-19 was reported positive on hospital day 3. He remained in critical condition being treated with hydroxychloroquine and tocilizumab in addition to the standard medical management for septic shock and ARDS. Our case is unique in its atypical initial presentation and highlights the importance of early testing.

Keywords: Acute respiratory distress syndrome; End-stage renal disease; Novel coronavirus disease 19; Rennin-angiotensin-aldosterone system blockade; Viral sepsis.

Fig. 1

Imaging demonstrating progression of interstitial pneumonitis due to COVID-19 resulting in ARDS. a Chest X-ray sequence with interval increasing patchy opacities in both lungs consistent with evolving infectious process. b Chest CT showing new multifocal bilateral patchy groundglass opacities with a predominantly peripheral distribution. There is mild bibasal septal and centrilobular thickening. No evidence of pleural effusion or pneumothorax. There are small biapical subpleural blebs and mild centrilobular pulmonary emphysema in the upper lobes. No evidence of atelectasis. These findings are more consistent with atypical pneumonia which may be secondary to viral infection. Please correlate clinically. Differential considerations include pulmonary edema.

Fig. 2

The complex interplay between Angiotensin Receptor 2 and Rennin-angiotensin-aldosterone system blockade in pneumocytes. ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blockers; ARDS, acute respiratory distress syndrome; COVID-19, novel coronavirus 2019; DNA, deoxyribonucleic acid.