key: cord-0985182-57c7o573 authors: Alshoabi, Sultan Abdulwadoud; Haider, Kamel H.; Mostafa, Mahmoud A.; Hamid, Abdullgabbar M.; Daqqaq, Tareef S. title: An unusual and atypical presentation of the novel coronavirus: A case report and brief review of the literature date: 2021-04-12 journal: J Taibah Univ Med Sci DOI: 10.1016/j.jtumed.2021.01.014 sha: 1e68c0b58427ecff574b411f0576841388c19b7d doc_id: 985182 cord_uid: 57c7o573 The coronavirus disease 2019 (COVID-19) is a highly contagious novel infection that predominantly presents with fever and respiratory symptoms. However, COVID-19 can masquerade as an acute coronary syndrome, leg pain or swelling with venous thrombosis, loss of consciousness with cerebral venous thrombosis, confusion, limb weakness with brain infarction, facial neuralgia, acute conjunctivitis, acute appendicitis, and testicular pain. We report on a 42-year-old man who presented with mild symptoms of COVID-19. The patient's electrocardiogram showed an ST-segment elevation myocardial infarction (STEMI) due to a left coronary thrombosis. The patient was managed conservatively with medicines and had an uneventful recovery. Emergency physicians should have a high index of suspicion for the unusual presentations of COVID-19. ‫ﻰ‬ ‫ﻣ‬ ‫ﺜ‬ ‫ﻞ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻬ‬ ‫ﺎ‬ ‫ﺏ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺰ‬ ‫ﺍ‬ ‫ﺋ‬ ‫ﺪ‬ ‫ﺓ‬ ‫ﺃ‬ ‫ﻭ‬ ‫ﺃ‬ ‫ﻟ‬ ‫ﻢ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺨ‬ ‫ﺼ‬ ‫ﻴ‬ ‫ﺔ‬ . ‫ﻫ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﻗ‬ ‫ﺪ‬ ‫ﻣ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﺣ‬ ‫ﺎ‬ ‫ﻟ‬ ‫ﺔ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﺮ‬ ‫ﻳ‬ ‫ﺾ‬ ‫ﺫ‬ ‫ﻛ‬ ‫ﺮ‬ ‫ﻓ‬ ‫ﻲ‬ ٤٢ ‫ﻣ‬ ‫ﻦ‬ ‫ﻋ‬ ‫ﻤ‬ ‫ﺮ‬ ‫ﻩ‬ ‫ﻛ‬ ‫ﺎ‬ ‫ﻥ‬ ‫ﻳ‬ ‫ﻌ‬ ‫ﺎ‬ ‫ﻧ‬ ‫ﻲ‬ ‫ﻣ‬ ‫ﻦ‬ ‫ﺃ‬ ‫ﻋ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﺽ‬ ‫ﻛ‬ ‫ﻮ‬ ‫ﻓ‬ ‫ﻴ‬ ‫ﺪ‬ -١٩ ‫ﺧ‬ ‫ﻔ‬ ‫ﻴ‬ ‫ﻔ‬ ‫ﺔ‬ ، ‫ﻭ‬ ‫ﺗ‬ ‫ﻄ‬ ‫ﻮ‬ ‫ﺭ‬ ‫ﺕ‬ ‫ﺇ‬ ‫ﻟ‬ ‫ﻰ‬ ‫ﺍ‬ ‫ﺣ‬ ‫ﺘ‬ ‫ﺸ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﻓ‬ ‫ﻲ‬ ‫ﻋ‬ ‫ﻀ‬ ‫ﻠ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻘ‬ ‫ﻠ‬ ‫ﺐ‬ ‫ﺑ‬ ‫ﺴ‬ ‫ﺒ‬ ‫ﺐ‬ ‫ﺗ‬ ‫ﺨ‬ ‫ﺜ‬ ‫ﺮ‬ ‫ﻓ‬ ‫ﻲ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺸ‬ ‫ﺮ‬ ‫ﻳ‬ ‫ﺎ‬ ‫ﻥ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﺎ‬ ‫ﺟ‬ ‫ﻲ‬ ‫ﺍ‬ ‫ﻷ‬ ‫ﻳ‬ ‫ﺴ‬ ‫ﺮ‬ . ‫ﺗ‬ ‫ﻤ‬ ‫ﺖ‬ ‫ﻣ‬ ‫ﻌ‬ ‫ﺎ‬ ‫ﻟ‬ ‫ﺠ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻤ‬ ‫ﺮ‬ ‫ﻳ‬ ‫ﺾ‬ ‫ﺑ‬ ‫ﺎ‬ ‫ﻷ‬ ‫ﺩ‬ ‫ﻭ‬ ‫ﻳ‬ ‫ﺔ‬ ‫ﻭ‬ ‫ﺗ‬ ‫ﺤ‬ ‫ﺴ‬ ‫ﻨ‬ ‫ﺖ‬ ‫ﺣ‬ ‫ﺎ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻪ‬ . ‫ﻳ‬ ‫ﺠ‬ ‫ﺐ‬ ‫ﺃ‬ ‫ﻥ‬ ‫ﻳ‬ ‫ﻜ‬ ‫ﻮ‬ ‫ﻥ‬ ‫ﺃ‬ ‫ﻃ‬ ‫ﺒ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﻄ‬ ‫ﻮ‬ ‫ﺍ‬ ‫ﺭ‬ ‫ﺉ‬ ‫ﻳ‬ ‫ﻘ‬ ‫ﻈ‬ ‫ﻴ‬ ‫ﻦ‬ ‫ﻟ‬ ‫ﻸ‬ ‫ﻋ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﺽ‬ ‫ﻏ‬ ‫ﻴ‬ ‫ﺮ‬ ‫ﺍ‬ ‫ﻻ‬ ‫ﻋ‬ ‫ﺘ‬ ‫ﻴ‬ ‫ﺎ‬ ‫ﺩ‬ ‫ﻳ‬ ‫ﺔ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺘ‬ ‫ﻲ‬ ‫ﻗ‬ ‫ﺪ‬ ‫ﻳ‬ ‫ﺄ‬ ‫ﺗ‬ ‫ﻲ‬ ‫ﺑ‬ ‫ﻬ‬ ‫ﺎ‬ ‫ﻣ‬ ‫ﺮ‬ ‫ﺿ‬ ‫ﻰ‬ ‫ﻛ‬ ‫ﻮ‬ ‫ﻓ‬ ‫ﻴ‬ ‫ﺪ‬ -١٩ ‫ﻭ‬ ‫ﺧ‬ ‫ﺎ‬ ‫ﺻ‬ ‫ﺔ‬ ‫ﺃ‬ ‫ﺛ‬ ‫ﻨ‬ ‫ﺎ‬ ‫ﺀ‬ ‫ﺍ‬ ‫ﻟ‬ ‫ﺠ‬ ‫ﺎ‬ ‫ﺋ‬ ‫ﺤ‬ The coronavirus disease 2019 (COVID-19) is a highly contagious novel infection that predominantly presents with fever and respiratory symptoms. However, COVID-19 can masquerade as an acute coronary syndrome, leg pain or swelling with venous thrombosis, loss of consciousness with cerebral venous thrombosis, confusion, limb weakness with brain infarction, facial neuralgia, acute conjunctivitis, acute appendicitis, and testicular pain. We report on a 42-year-old man who presented with mild symptoms of COVID-19. The patient's electrocardiogram showed an ST-segment elevation myocardial infarction (STEMI) due to a left coronary thrombosis. The patient was managed conservatively with medicines and had an uneventful recovery. Emergency physicians should have a high index of suspicion for the unusual presentations of COVID-19. The novel coronavirus disease 2019 (COVID-19) is a highly contagious disease that originated in Wuhan, China in December 2019. The disease is caused by infection with the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The World Health Organization declared a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 JTUMED742_proof ■ 12 April 2021 ■ 2/6 global pandemic in March 2020. 1 COVID-19 patients Q2 typically present with fever, cough, myalgia, or fatigue. Less common features are sputum, headache, haemoptysis, and diarrhoea. 2 Some patients may develop dyspnoea and need intensive care. Anosmia and loss of taste are atypical symptoms that have been reported in some cases. 3 Patients may present with unusual or atypical clinical features that are not related to the respiratory system, which may mislead the diagnosis of COVID-19. 4 COVID-19 can present with or be complicated by several extrapulmonary manifestations like thrombosis, myocardial problems, acute coronary syndrome (ACS), acute renal injury, hepatocellular injury, gastrointestinal symptoms and signs, elevated blood sugar problems, neurological manifestations, ocular symptoms and signs, and dermatological features. 5 In our case, we report on a COVID-19 patient with atypical presentation. This work aimed to highlight the unusual, atypical, and strange clinical presentations of COVID-19 to alert physicians about them, especially during the ongoing pandemic. A brief literature review was performed using a PubMed search for the term "unusual presentation of 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 COVID-19." The review included published case reports available through PubMed in the English language from January 2020 to August 2020. A 42-year-old male patient presented to the emergency department with fever, dry cough, anosmia, and fatigue, and his nasopharyngeal swab reverse transcriptase-polymerase chain reaction (RT-PCR) test confirmed the diagnosis of COVID-19. The patient was advised to isolate at home and was given hydroxychloroquine 400 mg/day, azithromycin 500 mg/day, zinc 30 mg/day, and Paracetamol as needed. On the ninth day, the patient returned to the emergency department with recurrent retrosternal chest pain attacks radiating to the left shoulder and associated with nausea. The patient's temperature was 36.8 , his respiratory rate was 18 cycles/minute, his heart rate was 83 beats/minute, and his blood pressure was 130/80 mmHg. The results of his respiratory and cardiovascular clinical examination were unremarkable. The results of his chest x-ray were also unremarkable. Electrocardiogram (ECG) showed a normal sinus rhythm with left ventricular hypertrophy detected using aVL voltage and ST elevation in V3 to V6 that improved after two days of primary care (Figure 1a and b) . Serial cardiac troponin T (TnT) was elevated [first result was normal, second was 0.51, and third was 0.78 (normal is up to 0.04 ng per millilitre)]. Echocardiogram (ECHO) showed normal left ventricular systolic function, and ejection fraction (EF) was 60%, with normal wall motion and normal valves. The patient was admitted to the intensive care unit (ICU) dedicated to COVID-19 patients. On the tenth day, chest pain attacks increased, ECG showed ST elevation and biphasic T inversion with poor R progression in V3 to V6. The patient was diagnosed as STsegment elevation myocardial infarction (STEMI) and referred to a catheter laboratory (Cath lab) for possible primary percutaneous coronary intervention (PPCI) according to the local guidelines of STEMI during COVID-19. Coronary angiography through a right femoral approach was done, revealing a large thrombus in the middle left anterior descending (LAD) artery with post-interventional thrombolysis in myocardial infarction (TIMI) flow 3 and no significant stenosis (Figure 2a and b) . The left circumflex coronary artery and the right coronary artery (RCA) were normal. The patient was managed conservatively with Aspirin, Clopidogrel, beta blockers, Tirofiban, and low dose Heparin infusions for 72 h and continued on Enoxaparin for seven days. A follow up ECHO showed no new abnormalities, with normal systolic function and an EF of 69%. On the twentieth day, a follow-up coronary angiogram (CAG) showed partial resolution of the left anterior descending (LAD) artery thrombus with residual particles in situ (Figure 3) . The patient continued with triple treatment, with Aspirin, Clopidogrel, and Apixaban, and a CAG was arranged for after two months. SARS-CoV-2, which causes COVID-19, usually presents with fever and respiratory symptoms. However, it may present with unusual or atypical clinical features that are not related to the respiratory system and may mislead from a COVID-19 diagnosis. In this case report and brief review, we focused on the unusual and atypical clinical presentations of COVID-19. In the literature, we found cases reported with unusual or atypical presentations, like leg pain or swelling with venous thrombosis, 6e8 loss of consciousness with cerebral venous sinus thrombosis, 9 confusion, 10 acute conjunctivitis, 11, 12 left facial drop and arm weakness with brain infarction, 13 facial neuralgia with herpes zoster, 14 right iliac fossa pain like appendicitis, 15 and abdominal pain accompanied by testicular pain 16 (Table 1) . In this paper, we reported a case of COVID-19 that was diagnosed early with mild respiratory symptoms and then complicated with coronary thrombosis and typical myocardial infarction features. A similar case of STEMI with coronary thrombosis was reported by Shams et al. and successfully managed with PPCI. 17 Salido-Tahoces et al. reported another positive case of COVID-19 in a 62-year-old male who presented with asthenia and recurrent chest pain with ACS and proximal RCA stenosis and whose diagnosis was confirmed by CAG. 18 Similarly, Tedeschi et al. reported acute STEMI with a large coronary thrombosis in a 60-yearold man; they explained this by pointing to the presence of , severe acute viral infection itself can promote the formation of ACS by increasing the risk of plaque rupture and micro-thrombi, owing to systemic inflammation or a cytokine storm, or by causing hypoxemia and coronary spasm, leading to a decreased oxygen supply to the myocardium. 20, 21, 23, 24 Conclusion COVID-19 patients can present to emergency departments with vascular complications like acute coronary syndrome, as in the current case report. Other unusual and atypical presentations that have been reported include leg pain or swelling with venous thrombosis, loss of consciousness with cerebral venous thrombosis, confusion, acute conjunctivitis, limb weakness with infarction, facial neuralgia, right iliac fossa mimicking appendicitis, or testicular pain. Emergency physicians should be alert to the unusual presentations of COVID-19 during the pandemic. This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflict of interest to declare. The patient has given informed consent allowing the authors to publish his case and images. Authors contributions Q7 SAA wrote the initial and final draft of the article. KHH collected and organised data. MAM provided research materials. AMH analysed and interpreted data. TSD provided logistic support. All authors have critically reviewed and approved the final draft and are responsible for the manuscript's content and similarity index. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 JTUMED742_proof ■ 12 April 2021 ■ 5/6 Current coronavirus (SARS-CoV-2) epidemiological, diagnostic and therapeutic approaches: an updated review until Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China SARS-CoV-2 and the pandemic of COVID-19 Extrapulmonary and atypical clinical presentations of COVID-19 Extrapulmonary manifestations of COVID-19 COVID-19 presenting as acute limb ischaemia COVID-19 presented with deep vein thrombosis: an unusual presenting SARS-CoV-2 infection and thrombosis: phlegmasia cerulea dolens presenting with venous gangrene in a child First case of Covid-19 presented with cerebral venous thrombosis: a rare and dreaded case A unique presentation of delirium in a patient with otherwise asymptomatic COVID-19 Conjunctivitis as sole symptom of COVID-19: a case report and review of literature A patient with bilateral conjunctivitis positive for SARS-CoV-2 RNA in conjunctival sample Rare presentations of COVID-19: PRES-like leukoencephalopathy and carotid thrombosis COVID-19 and herpes zoster co-infection presenting with trigeminal neuropathy Can COVID 19 present like appendicitis? 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