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 Table of Contents  
POSTGRADUATE FORUM
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 31-34

Rapidly progressive dyspnea in an elderly diabetic


1 Department of Internal Medicine, A J Institute of Medical Sciences and Research Center, Mangalore, Karnataka, India
2 Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Center, Mangalore, Karnataka, India

Date of Submission15-Oct-2020
Date of Decision09-Nov-2020
Date of Acceptance10-Nov-2020
Date of Web Publication28-Jan-2021

Correspondence Address:
Dr. Vishnu Sharma
Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Center, Kuntikana, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jalh.jalh_5_20

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  Abstract 


Breathlessness is a common presenting symptom in the emergency room. Focused history, clinical examination, and proper stepwise evaluations are essential for early diagnosis and treatment. The most common presenting feature of nCovid19 pneumonia is rapidly progressive breathlessness. During this pandemic, we need to differentiate nCovid19 pneumonia from other causes for breathlessness. Here, we discuss the differential diagnosis for rapidly progressive breathlessness, how to evaluate a patient with suspected nCovid19 pneumonia and the role of chest computed tomography scan in nCovid19.

Keywords: High resolution computed tomography scan, nCovid19 pneumonia, rapidly progressive dyspnea, reverse transcriptase-polymerase chain reaction, viral pneumonia


How to cite this article:
Bhandary NM, Sharma V, Megha S N. Rapidly progressive dyspnea in an elderly diabetic. J Adv Lung Health 2021;1:31-4

How to cite this URL:
Bhandary NM, Sharma V, Megha S N. Rapidly progressive dyspnea in an elderly diabetic. J Adv Lung Health [serial online] 2021 [cited 2021 Mar 4];1:31-4. Available from: http://www.jalh.com/text.asp?2021/1/1/31/308271




  History Top


A 78-year-old male, known diabetic and hypertensive, was brought to the emergency room with a history of progressive breathlessness for 2 days. One week back, he had low-grade fever for 2 days, which was associated with generalized weakness, body ache, and anorexia. He developed nonproductive cough and progressive breathlessness 5 days after the onset of fever. He had no chest pain or hemoptysis nor any cardiac, gastrointestinal, urinary, or neurological symptoms. No history suggestive of aspiration or inhalation lung injury. No history of any psychiatric symptoms, no other significant illness in the past except for diabetes and hypertension. He was on regular medications for diabetes and hypertension. He was a lifelong nonsmoker and had no other addictions. He was a retired bank employee. He lives with his son and grandchild, who had fever for 2 days and then became symptom-free. He developed fever 4 days after his son had fever.

Question 1. Which of the following is MOST LIKELY in this patient?

  1. Lobar pneumonia
  2. Cardiogenic pulmonary edema
  3. Viral pneumonia
  4. Pneumothorax
  5. Pericardial tamponade


Answer – 3. Similar symptoms in the family members, fever, body ache, anorexia followed by cough and breathlessness after 5 days are classical of viral pneumonia.[1] Usually, lobar pneumonia will present with high-grade fever, productive cough, and pleuritic chest pain.[2] He had no cardiac symptoms. Spontaneous pneumothorax at this age without any history of underlying lung disease or smoking is uncommon.

During this nCovid19 pandemic, when a patient is received in the emergency room with the chief complaint of breathlessness, we should assess properly to decide the possible causes for the symptom. A quick, accurate, focused history directed toward the possible causes for acute breathlessness is essential when such patients are received in the emergency room.


  Causes for Acute Onset of Breathlessness Top


  • Respiratory causes – Acute exacerbation of obstructive airway disease, pneumonia, pneumothorax, pulmonary embolism, aspiration pneumonia, toxic gas/fumes inhalation, foreign-body aspiration[3]
  • Cardiac causes – Cardiogenic pulmonary edema, pericardial tamponade, myocarditis, left ventricular dysfunction, fluid overload
  • Metabolic causes – Diabetic ketoacidosis, acute renal failure
  • Psychological – Psychogenic dyspnea. Usually, psychogenic hyperventilation occurs in young individuals, more common in females, usually due to some underlying psychological illness[2]


Most of the viral respiratory illnesses begin with upper respiratory symptoms.


  Symptoms in Viral Upper Respiratory Infection Top


Most of the viral upper respiratory infections present with fever, headache, rhinitis, body ache and malaise, sore throat in varying combination and severity.[1]

Other symptoms include[4]

  • Conjunctival congestion, dry cough
  • Nausea, vomiting, diarrhea – More common in children
  • Anosmia, anorexia – Highly suggestive of nCovid 19
  • History of contact, similar symptoms in contacts, outbreak in the community, seasonal variations is other clues for a viral respiratory illness.


Some patients may present with complications following viral upper respiratory illness. nCovid19 is known to cause many complications. Viral pneumonia, venous thromboembolism; cardiovascular complications, acute kidney injury, acute liver injury, neurological complications and long COVID are the most common complications.[5]

Viral pneumonia usually follows a viral upper respiratory infection. Dry cough and rapidly progressive breathlessness, which usually start 4–5 days after the onset of upper respiratory symptom/initial fever are the first symptoms in viral pneumonia.[4] Elderly patients, underlying immunosuppression, diabetes mellitus, chronic renal disease, liver disease, hypertension, and ischemic heart disease are more prone to develop complications.[5] In any patient with suspected pneumonia, risk stratification is essential to decide further management. Due to comorbidities, impaired mucociliary clearance reduced respiratory muscle strength and reduced immune response with age are the major reasons for increased complications in the elderly.[4]


  General Physical Examination findings Top


  • Respiratory rate – 24 per min
  • Heart rate – 124 per min
  • Oxygen saturation (SpO2) – 88% on room air
  • No central cyanosis
  • Respiratory system and cardiovascular system examination did not reveal any other abnormality
  • Other systemic examination was normal.


Question 2. What is the MOST LIKELY diagnosis in this patient after the physical examination findings?

  1. Viral myocarditis
  2. Viral pneumonia
  3. Bacterial pneumonia
  4. Pulmonary edema
  5. Cardiac tamponade


Answer – 2. Breathlessness out of proportion to physical findings is highly suggestive of viral pneumonia.[4] In bacterial pneumonia, signs of consolidation are usually present. Normal cardiac examination excludes cardiac cause for breathlessness.

Stepwise evaluation is essential to arrive at a proper diagnosis. Choosing the essential and proper investigations for early, accurate diagnosis and management is crucial in seriously ill patients.

Question 3. Which of the following investigation is LEAST useful in this patient?

  • Chest X-ray
  • Electrocardiogram (ECG)
  • Echocardiography
  • Arterial blood gas (ABG)
  • Sputum examination


Answer – 5. In suspected viral pneumonia, sputum examination does not have any diagnostic value.[4] Moreover, it may increase the risk of disease transmission among healthcare workers and laboratory personnel.[6]

Chest X-ray posteroanterior view was done [Figure 1], which showed bilateral mid and lower zone non homogeneous opacities.
Figure 1: Chest X-ray posteroanterior view

Click here to view


Question 4. Which of the following is the MOST COMMON chest X-ray feature in viral pneumonia?

  • Pleural effusion
  • Bronchopneumonia
  • Lobar consolidation
  • Cavity
  • Mediastinal adenopathy.


Answer – 2. Most common radiological feature in viral pneumonia is bilateral, peripheral, basal predominant bronchopneumonia.[7] Other radiological features are rare in viral pneumonia.


  Further Evaluation Top


His total white blood cell (WBC) count was 2030 cells/cumm, Neutrophils 88% and lymphocytes 9%. Inflammatory markers were raise, renal function test, ECG, Echocardiography were normal.

Question 5. Which of the following is NOT a pointer toward viral infection?

  • Reduction in total WBC count
  • Thrombocytopenia/thrombocytosis
  • Increased prothrombin time
  • Lymphopenia
  • Increased WBC count with neutrophilia


Answer – 5. This usually occurs in bacterial infections.[4]


  Neutrophil-lymphocyte Ratio Top


Neutrophil-lymphocyte ratio (NLR) = (absolute neutrophil count, cells/μL)/(absolute lymphocyte count, cells/μL). Neutrophil and lymphocyte can also be entered as percentages. NLR is indicator of stress. It can be increased in any inflammatory or infectious disease. This is used as indicator of the severity of nCovid19.[5]


  Neutrophil-lymphocyte Ratio and Stress Level Top


  • 1–3 normal
  • 4–5 equivocal
  • 6–8 mild
  • 9–18 moderate
  • >18 severe


ABG analysis showed hypoxia with respiratory alkalosis. With the clinical and radiological findings nCovid19 bronchopneumonia was suspected.

Question 6. What is the next diagnostic investigation?

  • High-resolution computed tomography (CT) thorax
  • RT-PCR for COVID-19
  • Serological test for nCovid 19
  • Induced sputum for evaluation
  • Rapid antigen test


Answer – 5. In a suspected nCovid19 case, the next diagnostic investigation is rapid antigen test.[5] It gives a quick result in about 30 min and has high specificity. Sensitivity is around 50%. Since the viral load is high between 3 and 7 days of onset of symptoms, positivity will be higher if testing is done during this period. If this test is done later, it can be negative as the viral load reduces. Rapid antigen test can be used as a screening test. A negative test should be confirmed by RT-PCR within 2 days if pretest probability is high.[5] Gold standard for diagnosis for nCovid19 infection at present is RT-PCR. Viral culture was used in the initial days. Cultures take time, expensive, done only in a few centers can't be done on a large scale. Serological tests are not useful in the diagnosis of COVID-19. Positive serology indicates the person had infection. Hence, it is useful in epidemiological surveys to detect the incidence/prevalence of previous infection and herd immunity.[5]

Question 7. Which is a WRONG statement regarding RT PCR test in nCovid19?

  • Sensitivity is high
  • Negative report does not exclude nCovid19
  • Positive report indicates person is infectious
  • If the virus mutates, test may become negative
  • Not recommended for monitoring treatment of nCovid19 infection.


Answer – 3. The test detects viral RNA but does not differentiate between dead and live virus.[5] Hence, positive report need not indicate the person is infectious, especially after 14 days. Rarely, the test can be false positive also.


  On Further Evaluation of the Case Top


  • Rapid-antigen test for nCovid19 was negative
  • RT-PCR Swab for nCovid19 was negative.


The sensitivity of RT-PCR in the diagnosis of nCovid19 is around 90%. It can be negative when swab collection is improper, errors with transportation and processing the samples, early stage or late stage of the diseases.[5] Hence further evaluation is essential when pretest probability of nCovid19 pneumonia is high.

High-resolution CT scan of the thorax is useful in the diagnosis of RT-PCR negative, symptomatic cases.[8] CT changes usually appear 3–5 days after of the onset of initial symptoms of the viral illness. When rapid antigen test is not available and due to high workload RT-PCR results are delayed, CT scan can be used as a screening tool for triaging of suspect cases as normal CT rules out nCovid19 pneumonia. CT is helpful to differentiate other conditions which can mimic/coexist/complicate nCovid19 pneumonia.[8] The most common early CT abnormality is peripheral, multifocal, bilateral, lower lobe predominant ground-glass opacities.[9] Crazy paving pattern, consolidation may be seen at a later stage. In the stage of resolution, which usually starts after 10–15 days interstitial and reticular shadows, fibrosis, honeycombing, and traction bronchiectasis may be seen.[9]

High-resolution CT scan of the chest was done [Figure 2],[Figure 3],[Figure 4]. CT scan showed bilateral ground-glass opacities with crazy-paving pattern in all the lung fields with a predominantly peripheral distribution highly suggestive of nCovid19 pneumonia. Hence, the patient was initiated on standard treatment for nCovid19 pneumonia.
Figure 2: Chest CT scan axial view in the upper zone

Click here to view
Figure 3: Chest CT scan axial view in the mid zone

Click here to view
Figure 4: Chest CT scan axial view in the mid zone

Click here to view



  Further Details of the Case Top


He was treated as RT-PCR negative nCOVID-19 as symptoms, chest X-ray, and chest CT scan was typical. Supplemental oxygen was given along with standard care. Repeat RT-PCR done after 2 days was also negative. His inflammatory markers, which were raised on admission, reduced after 7 days of medications. He made uneventful recovery and was discharged after 8 days.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jennings LC, Anderson TP, Beynon KA, Chua A, Laing RT, Werno AM, et al. Incidence and characteristics of viral community-acquired pneumonia in adults. Thorax 2008;63:42-8.  Back to cited text no. 1
    
2.
Sahasrabudhe TR. Psychogenic dyspnea. Med J DY Patil Univ 2013;6:14-8.  Back to cited text no. 2
  [Full text]  
3.
Vakil RJ, Golwala AF. Physical Diagnosis: A Textbook of Symptoms and Physical Signs. 13th ed.. Mumbai: Media Promoters and Publishers; 2010. p. 33.  Back to cited text no. 3
    
4.
Sharma MV. Early diagnosis of viral pneumonia. J Pulmon 2019;3:1-3.  Back to cited text no. 4
    
5.
Centers for Disease Control and Prevention. Corona Virus Disease (COVID-19): Interim Clinical Guidance for Management of Patients with Confirmed Corona Virus Disease (COVID-19). Available from: http://cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. [Last updated on 2020 Sep 10; last accessed on ?2020 Oct 03].  Back to cited text no. 5
    
6.
Jain S. Epidemiology of viral pneumonia. Clin Chest Med 2017;38:1-9.  Back to cited text no. 6
    
7.
Lei J, Li J, Li X, Qi X. CT imaging of the 2019 novel corona virus (2019-nCoV) pneumonia. Radiology 2020;295:18.  Back to cited text no. 7
    
8.
Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, 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 Jul;158(1):106-116. doi: 10.1016/j.chest.2020.04.003. Epub 2020 Apr 7. PMID: 32275978; PMCID: PMC7138384.  Back to cited text no. 8
    
9.
Wang Y, Dong C, Hu Y, Li C, Ren Q, Zhang X, et al. Temporal changes of CT findings in 90 patients with COVID-19 pneumonia: A longitudinal study. Radiology 2020;296:E55-64.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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