Bilateral infiltrates in a health-care worker during the COVID-19 pandemic
Authors: Otmar Schindler, Gerald Steiner, Elisabeth Trattner, Eva Schmon, Wolfgang Kuebler, Eveline Kink
Journal: The Lancet Infectious Diseases (2021)

A 55-year-old female intensive care unit nurse presented to the emergency room of Hospital Graz II (Graz, Austria) with fever, night sweats, fatigue, and dyspnoea on exertion in March, 2020. The patient's medical history was unremarkable and she was a never-smoker. The patient had a negative SARS-CoV-2 oropharyngeal swab PCR test. The patient was prescribed paracetamol 500 mg twice a day for no longer than 1 week and the symptoms gradually improved over a period of 2 weeks. The patient reported continuous fatigue and exhaustion on minor activity, but returned to work after the 2 week period. During the following 6 weeks, she treated critically ill patients with COVID-19 at her workplace. After this period, she presented to the local emergency department with worsening dyspnoea, fever, and increasing fatigue. Chest x-ray showed confluent alveolar consolidations in the lower lobes without significant pleural effusions (figure). Blood gas analysis confirmed hypoxaemic respiratory failure (arterial oxygen partial pressure 55·6 mmHg). The patient was admitted to the COVID-19 ward of Hospital Graz II and repeatedly tested negative on SARS-CoV-2 PCR and antibody tests. Laboratory tests showed increased platelets (468 g/L), creatinine (1·0 mg/dL), ferritin (314·34 ng/mL), D-dimer (1583 μg/L), and C-reactive protein (74 mg/L). Immunological testing showed increased soluble interleukin-2 receptor concentrations (4161·8 pg/mL), but no other pathology. Blood cultures, PCR, and antibody testing for atypical viral pneumonia-causing pathogens, (1–3)-β-D-glucan, HIV, and Legionella pneumophila antigen were also negative. Empirical treatment with azithromycin 500 mg over 4 days and oxygen administration via nasal cannula at 2 L/min for 2 days was initiated. The patient was discharged after 5 days and a follow-up appointment at the respiratory outpatient clinic was planned for 2 weeks after discharge. The patient's symptoms continued until the follow-up outpatient appointment, thus laboratory and radiological results were reviewed and her medical history was taken again by another senior respiratory physician. The patient reported that she was a deer hunter and had been exposed to bank vole droppings before her symptoms started. Serum titres of IgM against Puumala virus were positive, indicating recent hantavirus infection. Symptoms were attributed to histologically proven post-infectious organising pneumonia and fully resolved without sequelae after treatment with prednisolone, starting at 50 mg/day, which was tapered over 5 months. The control chest x-ray done 7 months after initial presentation showed minor post-infectious abnormalities. Hantavirus is endemic in southern Austria and is transmitted via aerosolised rodent droppings. Hantavirus infection can cause haemorrhagic fever with renal syndrome, leading to purpura due to thrombocytopenia, renal failure, and hantavirus pulmonary syndrome. Hantavirus pulmonary syndrome is characterised by initial symptoms of fever, myalgia, cough, shortness of breath, diarrhoea, and sweating. Radiographical imaging typically shows bilateral interstitial and alveolar oedema and pulmonary infiltrates. Rapid progression to shock or respiratory distress can occur within hours. Treatment is symptom-based with oxygen and ventilatory or circulatory support as needed. Diagnosis is made via medical history and a whole blood antibody test. Radiographical imaging is non-specific. In the context of the COVID-19 pandemice, a patient's medical history can be misleading especially among health-care workers who have increased exposure to patients with COVID-19. Contributors OS and ET wrote the Clinical Picture. OS, GS, WK, and ET were directly involved in clinical management of the patient. ES and EK provided clinical expertise for the patient's care. GS, WK, ES, and EK critically revised the Clinical Picture. All authors approved the final version and agreed to be accountable for all aspects related to accuracy and integrity of the work. Informed consent was obtained from the patient. She approved the use of clinical data, images, and other clinically related material for scientific purposes and publication. Declaration of interests We declare no competing interests.