Case presentation
A 32-year-old female presented to emergency department with respiratory complaints. She reported repeated chest pain and mild dyspnea. Her medical history involves TS, Hypertension, and chronic kidney disease, which requires dialysis three times per week. Her stature is short and her chest is broad, which is consistent with TS. On physical examination, orthopnea and bilateral fine crackles has been noticed. Room air oxygen saturation was low. COVID-19 has been excluded after doing PCR test. She was admitted in intensive care unit due to unstable overall condition.
Initial blood works showed markedly elevated white blood cells (15.17 109/L) with neutrophils dominance (77.6%), Hemoglobin (9.6 g/dL), Hematocrit (28.3%), CRP (93 mg/L), and LDH (809 U/L). Other tests have been done including: Procalcitonin (11.5 ng/ml), IL-6 (62.3 ng/ml), and D-Dimer (7.31 ng/ml). Urea, Creatinine, and electrolytes are usually mildly elevated before dialysis. Tuberculosis has been excluded by Gene-Xpert.
Chest X-ray revealed bilateral peripheral infiltrations and ground glass opacities[Figure 1]. Infective pneumonia with hypoxia was the initial diagnosis. Also, a high anion gap metabolic acidosis was complicating her case. Later, a CT scan was ordered and revealed clear signs of bilateral bronchiectasis[Figure 2]. An echocardiogram showed slight left ventricular hypertrophy, unsignificant right atrial enlargement, and no coarctation of the aorta.
During her stay in the intensive care unit, she has been treated with broad-spectrum antibiotics, as ceteriaxone and metronidazole, non-invasive oxygen therapy, and repeated dialysis. She had a slow recovery process. Despite that, she has finally showed signs of clinical improvement and was discharged without any need of oxygen supplementation or bronchodilators.