Case presentation
A 27-year-old male patient with MS for the past 12 years has been referred to our center with complaints of cough, dyspnea, body pain, and fever, in April 2022. The patient was admitted to the hospital due to cough with sputum, myalgia, fever, sweating, and frequent outpatient treatment (the last appointment was about a week before hospitalization) due to the exacerbation of previous myalgia, and the initiation of cough, fever, and dyspnea. In June 2021, he was also hospitalized in another center for 5 days with fever, cough, and dyspnea due to COVID-19 infection, and treated with remdesivir and glucocorticoid. Eventually, he was this discharged, 24 hours after the termination of his fever.
He had also a previously-diagnosed RRMS for the past 12 years, which resulted in neurological symptoms such as blurred vision, headaches and paresthesia in the lower limbs. Due to the uncontrollable MS, intravenous (IV) injections of rituximab (1gr per 6 month) was applied. The last injection was in February 2022. He was also taking prednisolone (5mg daily) for maintenance therapy and other medications such as salmeterol plus fluticasone inhaler, montelukast, NAC, and aspirin.
On physical exam, his temperature was 38 °C; blood pressure, 125/80 mmHg; respiratory rate, 17 breaths per min; pulse rate, 88 beats per min; and oxygen saturation, 94% (without any oxygen therapy). His fever was during day, but the sweating was preferably overnight. He also had a dyspnea that made him unable to walk (FCIII). The patient’s cough contained yellow sputum, and the body pain was responsive to analgesic. He had symmetric chest wall movements and no crackles or wheezing was detected. However, we could find rhonchi. There was no evidence of organomegaly, tenderness, or rebound tenderness in the examination of abdomen and it was not distended. In the neurological examination, no abnormal findings were detected. His laboratory data on admission showed an increased LDH (2061 U/L) along with increased levels of hepatic biomarkers (Table 1). Moreover, the levels of CRP, ESR, and PCT were higher than normal range. Transthoracic echocardiography (TTE) revealed an increased pulmonary artery pressure (30 mmHg).
First, we were highly suspicious of infections; thus, we began empiric treatment with ceftriaxone. However, due to persistent fever, the suspicion of nosocomial infections, the progression of pulmonary lesions, and reduced oxygen saturation, we began treatment with piperacillin + tazobactam, vancomycin, and levofloxacin. Nevertheless, patient’s fever did not stop after the aforementioned empiric treatment and his conditions got worse. Therefore, we were highly suspicious of opportunistic infections such as Cytomegalovirus, tuberculosis (TB), pulmonary aspergillosis, and Pneumocystis jirovecii.
We also considered the probability of infection in other sites. Thus, echocardiography and abdominal and pelvic ultrasonography were performed and revealed to be normal. Accordingly, bronchoalveolar lavage (BAL) fluid was obtained through bronchoscopy and was assessed for infections. In the case of TB, both BAL smear and RT-PCR were negative. Aspergillosis was also excluded due to a negative level of galactomannan in the BAL. However, RT-PCR demonstrated that COVID-19 infection was still remained (cycle threshold of 27). Further, the cytological assessment of BAL fluid showed no evidence of malignancy. Pneumomediastinum and pneumothorax were also excluded on the CT scan images. In figure 1, the patient’s CT scan findings were demonstrated, on admission day, right before bronchoscopy, discharge day, and 3 months later.
On the 12th day, his conditions worsened and he was admitted to the intensive care unit, due reduced oxygen saturation (SpO2 = 88%), and treatment was switched to linezolid and imipenem. At this time, the result of BAL fluid, tested for Pneumocystis jirovecii by RT-PCR, turned out to be positive. Therefore, we started trimethoprim-sulfamethoxazole (treatment of choice for PCP) and dexamethasone. Following the treatment, his conditions improved and the levels of PCT and CRP decreased. He was discharged in May 2022.