key: cord-0930588-ismp2sf5
authors: Singhania, Namrata; Bansal, Saurabh; Singhania, Girish
title: An Atypical Presentation of Novel Coronavirus Disease 2019 (COVID-19)
date: 2020-04-20
journal: Am J Med
DOI: 10.1016/j.amjmed.2020.03.026
sha: 0226aa7524ac8b3c6a4acec8ad136775f3ec41ba
doc_id: 930588
cord_uid: ismp2sf5

nan

To the Editor A 71-year-old female with hypertension came to emergency department (ED) with complaints of syncope. She did not have chest pain, shortness of breath, fever or cough. Blood pressure was 152/70 mmHg, 139/75 mmHg and 128/75 mmHg at supine, sitting and standing position respectively. Temperature was 98.5°F, pulse 114 beats/minute, respiratory rate 18/minute and oxygen saturation 96% on room air. She was awake, alert and had clear lungs. Electrocardiogram showed normal sinus rhythm. Glucose was 143 mg/dL, sodium 136 mmol/L, potassium 4.0 mmol/L, creatinine 1.34 mg/dL (normal baseline) and normal Troponin. White blood cell (WBC) count was 4100/mm 3 with absolute lymphocyte count 0.64 K/mm 3 (normal 0.80 -5.00 K/mm 3 ).

Computed tomography (CT) of the head was negative. Chest radiograph showed calcified granuloma in the right upper lobe and clear lungs. She was diagnosed with orthostatic hypotension and was given intravenous fluids and was sent home from the emergency department.

She was brought in again 3 days later with altered mental status. She had no fever, chills, chest pain, cough or shortness of breath. Family denied sick contacts or recent travel. Blood pressure was 100/51 mmHg, pulse 94 beats/minute, respiratory rate 22/minute, temperature 98.0°F and oxygen saturation 96% on 2 L oxygen. She was lethargic. She had minimal crackles bilaterally.

Laboratory indices showed normal electrolytes, white blood cell count 4300/mm 3 (absolute lymphocyte count 1.0 K/mm 3 ). Pro-calcitonin was normal. Head CT was negative. CT Corticosteroids should be avoided because of the potential for prolonging viral replication. Drugs like Remdesivir and Chloroquine have potential benefit, but their safety and efficacy is unknown.

Negative procalcitonin, presence of lymphopenia and chest imaging made us suspect COVID-19 in our patient as she did not have any classic symptoms of fever and cough. Due to this ongoing highly contagious disease, we would like to inform the providers that altered mental status in an elderly patient can be an atypical presentation of COVID-19.

Clinical Characteristics of Coronavirus Disease