COVID-19 Clinical cases
Here is what your peers have shared about coronavirus on Figure 1.
This resource library is a complication of COVID-19 cases and resources.
Join healthcare professionals from around the world in sharing real-time clinical knowledge and first-hand experiences.
From Cleveland Clinic: The onset of ARDS
In more severe cases of COVID-19, patients can develop acute respiratory distress syndrome (ARDS), which is accompanied by a worse prognosis.
The onset of ARDS begins with viral entry into alveolar pneumocytes, which line the alveoli. The alveolus, featured in the video, facilitates gas exchange in the lungs...
The first report of complete autopsy findings in COVID-19 in the English language literature
A 77-year-old man with a history of deep vein thrombosis, hypertension and remote splenectomy developed severe weakness and shortness of breath after a 6-day history of fever and chills. After his wife noted gurgling sounds, he was rushed to medical care but suffered a cardiac arrest en-route and died soon after arrival at the hospital. He died before he could be ventilated or started on therapy. A compete autopsy was performed. Post-mortem nasopharyngeal and lung swabs were positive for SARS-CoV-2.
Kawasaki disease and COVID-19
More than 85 children in New York have developed a “multi-system inflammatory syndrome” believed to be associated with COVID-19, and at least 3 have died.
Patients can present days to weeks following an acute COVID-19 illness with persistent fevers, raised inflammatory markers, abdominal symptoms, and a rash. They may meet the full or partial criteria for Kawasaki disease. Some have developed cardiogenic shock, requiring intensive care. The majority of patients have tested positive for SARS-CoV-2 by PCR or have had positive serology indicating a previous infection.
If you’ve seen a patient present in this way, share the case on Figure 1 to help your colleagues.
Did the patient die from—or with—COVID-19?
Physicians are faced with many challenges during the COVID-19 pandemic, one of which is accurate determination of cause of death. While the cause may seem obvious in individuals who test positive for SARS-CoV-2 and die after a febrile illness that evolves into respiratory failure, not all cases fit this stereotype.
Cleveland Clinic shares two cases that offer insights into the underlying pathology of COVID-19 and illustrate how autopsies can clarify the cause of death in some cases.
The harm that comes from novel therapies
Our Chief Medical Officer, Dr. Josh Landy, is sharing his experiences in the ICU.
"One of the refrains I have heard a lot is that novel therapies don’t hurt, also known as the "what have you got to lose" strategy. Here are two X-rays that demonstrate the—often unpredictable—harm that comes from novel adjuncts.
This patient was admitted to the ICU with COVID pneumonia a few weeks ago, and due to a very high D-dimer level, empiric anticoagulation was initiated. The night prior to extubation, the patient's oxygen saturation plummeted, fresh blood appeared in the ventilator tubing, and the second X-ray was obtained."
Is this a new phase of the pandemic?
Our Chief Medical Officer, Dr. Josh Landy, is sharing his experiences in the ICU.
The newest patient, the one represented by the orange question mark, was admitted today and the last non-COVID patient was transferred to one of the two spillover units we are using (our CCU and PACU). This feels like a new phase of the pandemic.
What proportion of beds are devoted to COVID at your institutions?
A 40-year-old Iranian male, who works at a bank, presents with a two-week history of cough. He developed a fever two days prior to presenting, which was responsive to acetaminophen. He had since developed myalgia and dyspnea on exertion. When he presented to our emergency department, he looked unwell. Temp 39.5, BP 140/90, HR 100, RR 20, O2 sats 85% on room air.. He was dyspneic on exertion and had coarse crackles all over both lungs. We admitted him, started oxygen by nasal cannula and gave IV fluids and paracetamol. An ABG revealed...
Suspected COVID-19 in a 60-year-old female with diarrhea
A 60-year-old female with diabetes presented with a history of digestive symptoms. Five to six days ago: Intense bouts of diarrhea and stomach cramping which lasted 2 days. Three to four days ago and continuing: Increasingly worsening myalgia and body aches, worse at night, preventing sleep. Today: slight tightness in left lung area and slight dizziness. Her O2 sats appear normal. No fever at any point since onset of symptoms. Patient has been on bed rest and taking higher doses of Zn, Ca, and K supplements. Could this be COVID-19? Any advice on how to proceed?
Could these be a cutaneous manifestation of COVID-19?
A 45-year-old female had some mild symptoms that might suggest COVID-19 in the past 3 weeks (no fever, but mild rhinitis and cough). She has had these painful chilblains since the first week. Nasopharyngeal PCR for SARS-CoV-2 is negative. Blood tests are pending. Have you encountered patients with similar presentations?
Pulse-temperature deficit in COVID-19
We have seen the first 2 cases of COVID-19 at our critical access hospital. The first is a 71-year-old male with interstitial lung disease (“farmer’s lung”) on chronic prednisone and home nocturnal O2 at 5 liters with BiPap. The second is a fit 79-year-old female, who is prediabetic and on no home meds. Both patients have pneumonia, are on maximum, non-invasive ventilatory support, and their prescribed meds include hydroxychloroquine/ azithromycin/ VitC / zinc etc. Both with rising ProBNP responding to diuretics. Both DNRs. Observation: These patients exhibit pulse-temperature deficit, i.e. relative bradycardia. With temps of 103 and pulses in the 70s. With any stimulation or agitation, O2 sats plummet with no rise in pulse... Has anyone else noticed this?
She was discharged after a week-long admission with COVID-19
64-year-old female with hypertension and hyperlipidemia, discharged after a week-long admission with COVID-19. Her initial chest X-ray was performed at an ED and cefuroxime/doxycycline were prescribed. Her COVID test subsequently returned positive and she experienced worsening symptoms of cough and dyspnea...
COVID-19: The happy hypoxic patient
EM clinicians are seeing COVID patients talking and alert with sats in the 60s. Many are comparing the pathophysiology to HAPE as opposed to ARDS or high compliance vs. a low compliance disease state. These patients are being intubated very early and clinicians are using the ARDsNET table to target PEEP to the FiO2 requirements. With mortality at 50-80% when ventilated are we missing something here? Should we tolerate lower saturation goals? Should we hold off on intubation and employ a NIV approach? Is anyone using epoprostenol?
He is staying with a friend who is a Physician and COVID-19 positive
A 72-year-old male present to the ED with shortness of breath. He lives in India but has been unable to return due to canceled flights. He is staying with a friend who’s a physician and COVID positive. He reports fever and cough for 8 days. His max fever is 103. He has been taking hydroxychloroquine for the past 3 days and states his home O2 sat was 88%. The patient denies chest pain along with nausea and vomiting. He takes Tylenol regularly for his fever, the last dose was this morning.
Temp 36.9, BP 174/98, HR 85, RR 20, SpO2 88% RA.
Possible false negative COVID-19 result
50-year-old male with diabetes and a history of hypertension presented to the ED with SOB, lethargy, dry cough, temp of 103, and was about a 7 on the MEWS scale. Respiratory panel done to rule out everything else was negative. Decided to test for COVID-19, results came back negative. Admitted him for sepsis and pneumonia. Day 4 symptoms have worsened. He remains febrile between 102-104, hypotensive, tachy around 134, and respiratory rate is between 26-28. We still can’t figure out where the infection is coming from. I strongly suspect the COVID test could’ve been a false negative, but they are refusing to test him again. Any suggestions?
“I would expect worse symptoms and O2 requirements given the chest X-rays”
64-year-old male with hypertension, DM2, and OSA was admitted with cough, malaise, and subjective fevers for 10 days. He had lymphocytopenia, normal procalcitonin, and mild elevations of ferritin and d-dimer. He is COVID positive. SpO2 stayed in the low 90’s on 2 L, worsened requiring 4-5 L NC, and then improved to low 90’s on room air at rest by the time of his discharge on day 7. Interesting thing about this case is the discordance in his chest X-ray findings between day 1 and day 6, and his symptoms and O2 requirements. I would expect worse symptoms and O2 requirements given the chest X-rays. He received 5 days of azithromycin and hydroxychloroquine.
Q&A with a hospitalist caring for COVID-19 patients
I start a 9 day stretch taking care of 5 COVID patients. I’ll present each case throughout the week as well as new ones that come along. What information are you interested in hearing about?
Follow hospitalistdoc to see their new COVID-19 cases.
CT showed extensive pneumonia, presumptive for COVID-19
A 47-year-old female presented to the ED with shortness of breath, fever, cough, and hypoxia for the past 4 days. Her initial vitals were: Temp 39.2C, BP 90/64, HR 121, RR 24 and shallow, and SpO2 88% on room air. She’s an RN at a skilled nursing facility with a couple of ill residents but no testing had been performed. She reports that 3 days ago she had to leave work because she was short of breath. An IV was established, labs were drawn and flu, strep, RSV, and COVID-19 swabs were obtained. A 500 mL bolus was administered and the patient was placed on 3 LPM of O2 via nasal cannula to maintain SpO2 of approx 97%. A CT showed extensive pneumonia, presumptive for COVID-19...
Minimal symptoms with sudden hemodynamic collapse
“A 71-year-old AA female who had felt unwell and weak for 2 days with decreased oral intake, presented 12 hours following an episode of syncope. Her only other symptom on the day of presentation was diarrhea. She had a past medical history of breast cancer s/p mastectomy and radiation, radiation-induced pulmonary fibrosis, and HFrEF secondary to ICM. Temp 90.4, BP 118/64, HR 83, RR 15, SpO2 100% RA. She was profoundly dry on exam but A&O x3. A chest X-ray showed cardiomegaly with mild congestion. She was given 1L of IV fluids over 2 hours. Na dropped from 119 to 117, and an EKG showed QTc514. She deteriorated rapidly, BP 74/54, HR 70, RR in 20s, SpO2 100% RA. She tested positive for COVID-19…” See the full case
Confirmed outpatient COVID-19 case
A 34-year-old woman in Southern California who’s symptoms began in the middle of March with eye and sinus pressure, and loss of taste/smell. 2-3 days later, she developed headache, fatigue, and mild body aches. 1 day later she developed a fever, cough, and shortness of breath. The patient called the city to get tested and was directed to a drive-through testing facility. She self-quarantined for 5 days until a positive SARS-COV-2 test returned. Her fevers resolved in those 5 days, cough is minimal, some headache, sense of smell/taste returned. Her partner at home has since developed symptoms.
ARDS and Ventilator Management for COVID-19 Case Study
63-year-old woman with COVID-19 is admitted to the hospital for septic shock secondary to CAP. After receiving hydroxychloroquine, antibiotics (which include azithromycin), fluids, and vasopressors, her condition stabilizes. However, she subsequently develops ARDS and is intubated. Her oxygen requirement increases until she is receiving 100% oxygen. Ventilator settings are in the volume-controlled continuous mandatory ventilation mode with RR 22, TV 330 mL (6 mL/kg of ideal body weight), FIO₂ 100%, and PEEP 5. Peak pressure of 25 cm H₂O, and a plateau pressure of 22 cm H₂O...
Thanks to Dr. Raj Dasgupta for sharing this teaching case.
A call for chest X-rays to develop new COVID-19 screening tool
Researchers at the University of Waterloo and Darwin AI have launched an open-source project to improve COVID-19 screening using artificial intelligence and chest X-rays.
The team is currently looking to collect more chest X-ray data, which is needed to teach the AI models they are building. Do you have chest X-rays (PA or AP view) of patients with COVID-19? Share them on Figure 1 using the hashtag #covid-19 or via the link below to contribute to the project.
All data and learnings from this initiative will be made publicly available to the community.
Critical Case of COVID-19
A 42-year-old male patient presented to ED with a two-day history of fever and mild shortness of breath. He had no other symptoms, no past medical history — although he is an ex-smoker. He had high-grade fever and O2 Saturation of 91-92 on room air. Chest examinations revealed bibasal fine crepitations. His chest X-ray shows cannon ball opacities in both lung fields. ABG shows T1RF. Basic Blood tests show lymphocytopenia, raised inflammatory markers and stage 1 AKI. Patient was initially admitted to the ward but he rapidly deteriorated and developed haemoptysis and severe shortness of breath. CT CAP with contrast shows classic COVID-19 infection with CT severe score. No other abnormalities in abdomen or pelvis. His nose and throat swab tests are positive for COVID-19 four times.
After three days, he required intubation
A 55-year-old male presented with shortness of breath,progressive cough, and fever over several days. He came back from a holiday in the western part of Austria 5 days earlier. His medical history includes depression which is being managed with antidepressants. The patient tested positive for COVID-19.
This is his X-ray at admission; PaO2 58 mmHg in room air. After 3 days, respiratory failure occurred leading to intubation.
Case update: Young adult who required ventilation is now recovering
An update to a case of a 33-year-old male that was shared on March 20. After presenting with a 10-day history of malaise and dry cough, then 3 days of haemoptysis, shortness of breath, and pleuritic chest, he was admitted to ITU for respiratory support, initially for optiflow, but required intubation and ventilation. He completed one week of tazocin and tamiflu. He did not require inotropes or vasopressors during admission. He was successfully extubated and gradually weaned from BIPAP to a nasal cannula. He was fit for ward level management. On the ward his oxygen continued to be weaned and he mobilized independently without oxygen. He improved significantly with complete resolution of inflammatory markers and no oxygen requirement. He was discharged with no medications.
“CT chest shows extensive bilateral infiltrates”
73-year-old female with a history of cardiac disease, who was admitted for abdominal surgery from a nursing home. She developed shortness of breath and fevers during her hospital stay. CT chest shows extensive bilateral infiltrates, last image shows CT chest compared to three days earlier. She tested positive for COVID-19 and eventually passed away.
Covid-19 positive and recovering
A 49-year-old male pharmacist presented to the ER with a cough. Flu-like symptoms, sore throat, and mild shortness of breath developed over the next 3-4 days. He has a past medical history of hypertension and no travel history outside the US. The patient was tested for flu and COVID-19 and was sent home to self-quarantine. The next day, the patient was informed that his flu results were negative. He self-dosed with one tab of chloroquine and his symptoms got worse. Two days later, he was confirmed to be #Covid19 positive, at which point he increased his dose and took 2 tabs daily for 7 days. The patient is currently symptom free with residual cough.
Imaging findings are highly suggestive of COVID-19, but swab is negative
A 67-year-old gentleman came in because of shortness of breath, low-grade fever and general malaise. PMHx asthma. SHx Taxi driver in London. CXR showed bilateral patchy consolidation, with elevated CRP, mildly elevated WCC. Desaturation on room air to 90%. Covid-19 sample came back negative, thus was treated for CAP with Co-amoxiclav. Patient didn’t improve and was still hypoxic on room air 93% saturation. A repeat Covid-19 swab was negative and we did a CT scan to rule out PE. Radiologist reported three features from China and the US highly suggestive of Covid-19: Peripheral distribution, ground glass opacification, bronchovascular thickening, craving paving.These findings were highly suggestive of atypical viral pneumonia COVID-19. (P<0.01).
A young, healthy female now on ECMO
A 27-year-old healthy female presented to the ED with complaints of cough, low-grade fever, and shortness of breath. She was tested for COVID-19 and admitted to the floor and started on Tamiflu, Plaquenil, and Kalentra. After 3 days she developed worsening SOB and was placed on 100% non-rebreather and the critical care team was consulted. She appeared tachypneic, tachycardic, and was using accessory muscles. She was emergently transferred to the ICU and intubated, requiring 100% FiO2 and 10 of PEEP to maintain a saturation above 90%. CXR revealed a mild patchy infiltrate of the RLL. The following morning her oxygenation improved but a decision was made to transfer her to our associate hospital for a higher level of care that offered proning and ECMO.
A 28-year-old male with confirmed covid-19
28M previously fit and well, not on any regular medications, presented with a 6-day Hx of fever, non-productive cough and SOB for the last 4 days. His symptoms started as sore throat and coryzal symptoms 8 days prior to his presentation. He reported contact with a friend with similar symptomatology.
O/E: T:39.1 HR:87 BP:119/63 RR:38 SpO2 90% on RA. Bilateral nasal crepitations without a wheeze.
She had recently been on a cruise 17 days earlier
A 49-year-old female with a history of asthma presented with some fatigue, flu-like symptoms, and shortness of breath over a span of a week. Testing came back positive for COVID-19. She was doing well so asked to self quarantine. Images show the spectrum of disease compared to the last COVID case I presented. Here there was only patchy ground glass opacities present on the right lung on CT chest. Only lab finding was mild leukopenia
"COVID-19 is not a joke"
65-year-old female with uncontrolled type 2 diabetes with HgbA1c 12.8% and hypothyroidism was on a cruise ship, developed cough and altered mental status. She was diagnosed with pneumonia and developed significant respiratory decline requiring mechanical ventilation. Labs showed diabetic ketoacidosis, which has now resolved. Initial chest shown with acute respiratory distress syndrome (ARDS). Found to be #COVID-19 positive. Patient paralyzed, sedated, ventilated and in RotoProne bed without improvement.
Initial symptoms were flu-like
A 63-year-old patient presented with shortness of breath and chest pain, after returning from a holiday abroad in February. PMH of diabetes and hypertension. Initial symptoms were flu-like for 1 week and on admission, he had a spiking temperature of 39 degrees. Treated for CAP, and within 72 hours Covid-19 was positive. Few days into admission, patient was unable to maintain his saturation and was later intubated and is in ITU, on day 12 now.
Responded to 32 y/o Female with chief complaint of difficulty breathing and in and out of consciousness. Female had no travel history out of the state and only medical history was asthma. Upon our arrival we took PPE precautions and found the female in her room laying supine sleeping. Female reported she had developed a dry cough within the last couple of weeks. Her fever had progressed and she couldn’t catch her breath...
He was tested for COVID-19 and admitted
A 80-year-old healthy male presented to the ED with complaints of cough, high-grade fever, and shortness of breath for five days. His O2 saturation is 90% on room and 95% on 8 litres of oxygen via non-rebreather mask.
64F transferred from a non-PCI center. Troponin-I 18 and CKMB 70. Cath showed non-obstructive CAD, but was found to be in shock and placed on IABP. Echo with EF 40% and markedly increased wall thickness. No lung pathology. Tested positive for COVID...Thoughts?
Thanks to Dr. Issa Kutkut for sharing this case.
COVID-19 triage protocol best practices
What protocols are you currently using to triage PUI? What are you using for remote (phone/video) vs in-person triage? What thresholds are you using to order testing vs sending home? Related to the above, are you sending samples to the CDC lab or do you have local/private labs available to test specimens?
CT imaging of a 61-year-old female from China with confirmed COVID-19
These CT images demonstrate multiple ground-glass opacities, some of them with reticulation. There are small foci of consolidation involving all pulmonary lobes, with predominant distribution in the posterior and peripheral parts of the lungs, especially in the lower lobes, where most of the opacities spare the immediate subpleural parts of the parenchyma (subpleural sparing).
Case provided by Raioss, a Brazilian startup that works with AI in radiology and PACS that developed Coronacases.org - a platform that allows HCPs worldwide to see and learn from COVID-19 cases.
Symptoms started 10 days after returning from Italy
Patient 1977/Male, went on a ski trip in Italy. Came back 08.03.2020. The first signs started after 10 days with temp 40*C, dyspnea, coughing, headache. Went to the testing centers and came positive for COVID-19. Blood work-up is not so dramatic with a very low CRP and PCT. The rtg thorax shows signs of atypical pneumonia. Patient had problems breathing. Without O2 88% with 2L O2 97%. After the first day, the patient was transferred to the ICU and intubated.
No illness history, non-smoker, fit.
Prior to being in Colombia, she traveled throughout Europe
26-year-old female who traveled from Colombia to NYC presented to the ED with dyspnea and cough. She wasn’t febrile during triage. HR was 126 and she was saturating at 94% on RA and wearing a face mask. No pertinent PMH. She stated prior to being in Columbia, she traveled throughout Europe from December to February. Immediately placed into COVID isolation after triage. #COVID-19. I apologize for the grainy image.
A 28-year-old with a history of recent travel to Europe
28-year-old, recent travel to Europe, fever, shortness of breath, cough with later hemoptysis, myalgias. On labs: low WBC, otherwise unrevealing, including negative influenza. Due to strong suspicion of COVID19, CT ordered with following images.
Early clusters of COVID-19 or something else?
In mid to late January we saw about 15 patients in our clinic with high fever (up to 104), headache, sore throat, dry cough, weakness, and watery diarrhea…several needed IV fluids for dehydration. Do not know if any ended up in hospital. We were not aware or thinking of #COVID-19 at the time.
Collated imaging findings from #COVID-19 patients
Dr. Daniel Ortiz, a radiologist in Georgia, collated the imaging findings from several #COVID-19 patients at one of his hospitals over five days. See the findings:
He deteriorated and required invasive support
A 33-year-old male presented to the ED with 10 days of malaise and dry cough, then 3 days of haemoptysis, shortness of breath, pleuritic chest pain and dizziness. He has no past medical history but he is morbidly obese (BMI 58.1 kg/m2)...
How are other 911 systems handling this?
A 51-year-old male, suspected covid patient, was transported by EMS. The patient is awaiting test results from the department of health and was asked to isolate. How are other 911 systems handling this?
Would you swab this patient for the virus?
50+ male patient, asthmatic, returning from a COVID-19-affected European country a few days earlier. Started to feel unwell before departure with fever and shortness of breath. No wheeze, hypoxia, tachypnea or tachycardia on assessment, only pyrexial with persistent dry cough. Arterial blood gas readings are all within range. Would you admit this patient? Would you swab this patient for the virus? Does the fact that he is asthmatic make a difference to your decision making? Would you prescribe antibiotics?
No cough, runny nose, or sore throat — Tested positive for COVID-19
A 30-year-old female presented with a history of neck pain and headache for less than a week. No cough, runny nose, or sore throat. My colleague was concerned about meningitis and sent the patient to the emergency department for evaluation. She was assessed, tested for #COVID-19, and discharged home. The test came back positive two days later. Should triage nurses and staff at the front desk be given PPE?
She didn't meet CDC guidelines for COVID-19 testing — how many cases are we missing because of this?
30-year-old healthy female flight attendant presents with a 5 day history of shortness of breath after returning from Australia. Lives in California, US. Non-smoker, no known past medical problems. Initial oxygen saturation on room air was 90%. Chest X-ray showed bilateral basilar infiltrates. Lab results negative. She was given Duoneb HHN, IV fluids, and admitted to telemetry. She didn't meet CDC guidelines for COVID-19 testing (febrile only 99.5) but a sample was collected and sent to a private lab - turnaround is 72 hours. Currently awaiting results. The patient is stable and maintaining oxygen saturation of >95% on 2 liters O2. How many cases of COVID 19 are we missing because they do not meet CDC criteria for testing? See the full case
Rapidly developed hypoxemic respiratory failure
44-year-old male with untreated DM2 (A1C 11), no other medical issues or comorbidities, now confirmed #COVID-19. He presented with 1 week of GI-predominate symptoms (epigastric pain, poor PO, 1 episode of vomiting at onset). Progressed to myalgias and non-productive cough but really presented for GI symptoms. Hypoxic to low 90s on RA at presentation, febrile to 101. Rapidly developed hypoxemic respiratory failure over the course of several hours, RA -> max NC -> non-rebreather. So far not requiring intubation. Started on trial of liponavir/ritonavir. Left - CXR at presentation, Right - several months prior.
Paralyzed, proned, and being considered for ECMO
Female, over 65, with confirmed #COVID-19 who presented with fevers and worsening shortness of breath and diffuse bilateral ground glass opacities and consolidations. She is being treated for ARDS and currently on lung protective ventilation, paralyzed, proned and being considered for ecmo.
What are your strategies for supportive treatment?
CT thorax of a patient with confirmed COVID-19 sent to me by a colleague from a widely affected country. The patient is in mid 50s and has been otherwise well. CT images obtained 20 days earlier do not demonstrate any pulmonic infiltrates, however there is extensive involvement in current imaging. The patient has the clinical presentation of a case of severe chest sepsis. Knowing what we know thus far, what are your observations and strategies for supportive treatment? [ECMO not available]
When do you proceed to intubate assuming this is COVID-19?
Patient in early 50s who has a history of SARS when it was going round. Presents with shortness of breath, oxygen saturation in high 80s despite no chronic pulmonary disease. The patient seems to be coping well, but when do you decide to proceed to intubation assuming this is COVID-19? Watch and observe until they begin to deteriorate, or intubate while still well?