CASE REPORT: Here, we present a case of a young man who has childhood asthma with the last attack more than 10 years ago presented with symptoms suggestive of acute exacerbation of bronchial asthma. As the symptoms failed to improve after standard asthma management, anaphylaxis was suspected, and he was given intramuscular adrenaline 0.5 mg which leads to symptom improvement. However, he developed another attack shortly after improvement while under observation.
CONCLUSION: The objective of this case report is to emphasise the importance of keeping anaphylaxis in mind whenever a patient has treatment-refractory asthma, and also the anticipation of biphasic reaction that warrants adequate observation period especially those who are likely to have developed it.
CASE PRESENTATION: However, here we report a case of DNPE with a slightly different presentation where there is no preceding trauma and has symptoms that mimic severe pneumonia. He presented with high fever, dyspnoea and pleuritic chest pain. Despite on 10 L of oxygen supplementation via high flow mask and already given bolus intravenous antibiotic, the patient still tachypnoeic and was persistently in type I respiratory failure. His chest X-ray showed consolidative changes. Upon further investigation revealed no evidence of DVT on Doppler ultrasound and normal D-dimer level. Due to the high index of suspicion by the attending physician, PE was suspected and later confirmed with computed tomography pulmonary angiography scan. He was successfully treated with anticoagulation therapy. The objective of this case report is to share the difficult experience of diagnosing PE when the presentation highly atypical and mimics severe pneumonia.
CONCLUSION: And with such a masquerading presentation, one can easily miss the diagnosis. To the best of our knowledge, there are very few similar cases reported.
METHODS AND ANALYSIS: This mixed-method project has two phases. In phase 1, we will identify a list of patient-reported and clinical outcomes through qualitative research and systematic reviews. In phase 2, we will categorise the identified outcomes using the Core Outcome Measures in Effectiveness Trials taxonomy of core domains and the International Classification of Functioning, Disability and Health. We will develop questionnaires from the list of outcomes identified from each domain for the two-round online Delphi exercise, aiming to reach a consensus on the COS. The Delphi process will include patients, carers, researchers and healthcare participants. We will hold an online consensus meeting involving representatives of all key stakeholders to establish the final COS.
ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Ethics Committee for Research Involving Human Subjects, Universiti Putra Malaysia and the Research Ethics Committee, National University of Malaysia. This proposed COS in TD will improve the value of data, facilitate high-quality evidence synthesis and evidence-based decision-making. Furthermore, we will present the results to participants, in peer-reviewed academic journals and conferences.
REGISTRATION DETAILS: Core Outcome Measures in Effectiveness Trials (COMET) Initiative database registration: http://www.comet-initiative.org/studies/details/1371.
METHODS: This is a retrospective observational study where 25 male in-patients with laboratory-confirmed COVID-19 in Hospital Canselor Tuanku Muhriz. Demographics, clinical data and CT images of these patients were reviewed by 2 senior radiologists.
RESULTS: In total there were 25 patients (all males; mean age [±SD], 21.64±2.40 years; range, 18-27 years). Patients with abnormal chest CT showed a relatively low normal absolute lymphocytes count (median: 2.2 x 109/L) and absolute monocyte count (median: 0.5 x 109/L). Lactate dehydrogenase was elevated in 5 (20%) of the patients. The procalcitonin level was normal while elevated levels of alanine aminotransferase, total bilirubin, platelet and C-reactive protein were common. Baseline chest CT showed abnormalities in 6 patients. The distribution of the lesions were; upper lobe 3 (12%) lower lobe 3 (12%) with peripheral distribution 4 (16%). Of the 25 patients included, 4 (16%) had ground glass opacification (GGO), 1 (4%) had a small peripheral subpleural nodule, and 1 (4%) had a dense solitary granuloma. Four patients had typical CT features of COVID-19.
CONCLUSION: We found that the CT imaging showed peripheral GGO in our patients. They remained clinically stable with no deterioration of their respiratory symptoms suggesting stability in lung involvement. We postulate that rapid changes in CT imaging may not be present in young, asymptomatic, non-smoking COVID-19 patients. Thus the use of CT thoraxfor early diagnosis may be reserved for patients in the older agegroups, and not in younger patients.