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Year : 2021  |  Volume : 9  |  Issue : 4  |  Page : 259-263

A case report of pleural effusion in a COVID-19 patient with multiple comorbidities

Department of Medicine, Bowring and Lady Curzon Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission23-Oct-2020
Date of Decision28-Nov-2020
Date of Acceptance13-Mar-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Dr. C N Mohan
#312/A 6th Main, 4th Block, 3rd Stage, Basaveshwara Nagar, Bengaluru - 560 079, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_82_20

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We report a case of coronavirus disease 2019 (COVID-19) infection in a patient with multiple comorbidities diabetes, hypertension, ischemic heart disease, and chronic liver disease. Although pleural effusion is rarely seen in COVID-19 infection, the presence of which should be interpreted carefully. In this case report, our patient presented with complaints of fever, cough, and dyspnea, and focused clinical examination revealed fullness in the left hemithorax compared to right; reduced chest movements in the left hemithorax and trachea deviated to the right; dullness in the left hemithorax and right infrascapular, infra-axillary, and mammary area; and absent breath sounds in areas where dullness was noted. A chest X-ray done revealed left massive pleural effusion with right mild pleural effusion and pleural fluid analysis on both sides revealed transudate picture; this was also similar to the ascitic fluid analysis that was done in this patient; at this point of time, a computed tomography of the thorax was done to rule out other causes of pleural effusion. Meanwhile, other laboratory investigations revealed evidence of liver cell failure showing hyperbilirubinemia, hypoalbuminemia, and deranged prothrombin time and international normalized ratio (INR) and imaging evidence of cirrhotic liver; the patient was treated accordingly. Therapeutic pleural tapping was done after INR normalized; the patient improved symptomatically. Pleural effusion although is a rare manifestation of COVID-19, the etiologies are varied, it is important for us to consider other possible comorbidities associated in a patient who is hospitalized for acute illness, in this case, the patient had multiple comorbidities such as diabetes, hypertension, ischemic heart disease, and chronic liver disease, and the cause for pleural effusion is attributed to decompensated chronic liver disease and ischemic heart disease. In this case, the acute infection has resulted in the decompensation of his preexisting chronic disease.

Keywords: Chest X-ray, coronavirus disease 2019, pleural effusion

How to cite this article:
Mahendra M, Siddesh N, Mohan C N, Narayanaswamy M. A case report of pleural effusion in a COVID-19 patient with multiple comorbidities. APIK J Int Med 2021;9:259-63

How to cite this URL:
Mahendra M, Siddesh N, Mohan C N, Narayanaswamy M. A case report of pleural effusion in a COVID-19 patient with multiple comorbidities. APIK J Int Med [serial online] 2021 [cited 2022 May 20];9:259-63. Available from: https://www.ajim.in/text.asp?2021/9/4/259/328685

  Introduction Top

In December 2019, novel coronavirus disease 2019 (COVID-19) exploded out in Wuhan, China. The pathogen, severe acute respiratory syndrome coronavirus 2, is a novel β-coronavirus and transmitted mainly through droplets and close contact. It is highly contagious and can spread quickly such that the entire human population is susceptible. Patients often presented with respiratory symptoms and fever 5–6 days after being infected with the virus (latency period ranging 1–14 days). Most cases develop into mild infection that subsides on its own, but severe cases often lead to death, especially in elders and patients with associated comorbidities.[1] The clinical expressions of COVID-19 range from asymptomatic course to mild-to-severe form, characterized by dyspnea and/or hypoxemia that can quickly progress to septic shock, refractory metabolic acidosis, coagulation disorders, need for intensive care, and death in 4.3%–15% of patients.[2] Early disease progression can be rapid.[3] The severe clinical form is characterized by abnormal laboratory findings, such as hyperferritinemia, leukopenia, alterations of liver function tests (LFTs), and high levels of cytokines (i.e., interleukin (IL)-6, IL-1B, IL-1RA, IL-2, IL-10, and tumor necrosis factor α)[3],[4] and chemokines such as inducible protein-10 and monocyte chemoattractant protein-1.[5],[6] Liver injury in patients with coronavirus infections is often transient and can be directly caused by the viral infection of liver cells.[7] Several evidence suggest that the virus may induce a proinflammatory state related to the overactivation of effector T-cells with associated massive production of proinflammatory cytokines that may play a key role in the development of the lung disease and damage, which in turn leads to acute lung injury.[8],[9],[10] In the absence of a specific treatment or vaccine for COVID-19, early diagnosis and the subsequent isolation of infected patients are essential for disease control.

Chest radiographs may be normal in early/mild disease. In those COVID-19 cases requiring hospitalization, 69% had an abnormal chest radiograph at the initial time of admission, and 80% had radiographic abnormalities sometime during hospitalization.[11] Findings are most extensive about 10–12 days after onset of symptoms.[11] The most frequent findings are airspace opacities, whether described as consolidation or, less commonly, ground-glass opacity (GGO).[11],[12] The distribution is most often bilateral, peripheral, and lower zone predominant.[11],[12] In contrast to parenchymal abnormalities, pleural effusion is rare (3%).[11]

Although cardiac manifestations of COVID-19 are well recognized, there is no published evidence of cardiac disease on chest radiographs.[13] Pleural effusion is seldom seen in COVID-19;[14],[15] it is seen that pleural effusion tends to occur with recurrent pneumonia or late in the course of COVID-19 pneumonia (beyond 3rd week). The incidence of pleural effusion is higher in other viral pneumonia compared to COVID-19 pneumonia (39% vs. 4%)[16] and also that pleural effusion is common in patients who are critically ill, 8% in mild symptoms, and 28% in critically ill.[17]

We report a case of COVID-19 infection in a patient who presented with left massive pleural effusion on chest radiography, which was the early sign and the presenting manifestation, and on careful history and investigation, it was found that this patient had multiple comorbidities. The causes for pleural effusion are often overlooked, as in this case; it appeared that COVID-19 pneumonia was the cause for the pleural effusion, but on careful investigation, the reason for effusion was due to decompensation of underlying chronic disease caused by acute infection. Thereby, a careful history and focused clinical examination are necessary in every case in conjunction with necessary investigations to make an accurate diagnosis and better treatment outcome.

  Case Report Top

A 50-year-old male presented with a history of hypertension, type 2 diabetes mellitus, and dyslipidemia for 12 years on regular medications. He was also a known chronic alcoholic for 10 years with last drink 7 months back. The patient also gave a history of ischemic heart disease status postpercutaneous transluminal coronary angioplasty (PTCA) 5 years back on cardiac medications. The patient is a street vendor by occupation and had completed his education up to the 8th grade. The patient satisfied cut-annoyed-guilty-eye (CAGE) criteria for alcohol dependence and had not undergone any deaddiction treatment in the past. This patient was referred to us from other hospital for further management. The patient presented with a history of shortness of breath, fever, and cough with expectoration for 2 days. In the current pandemic situation, the patient was suspected to have COVID-19 infection for which rapid antigen test (RAT) was positive. Upon arrival in the emergency room, the patient was found to be tachypneic and not maintaining saturation on room air (SPO2 96% with 4 l/min on face mask) and the rest of the vital parameters were within normal limits.

On general physical examination, the patient had pallor and icterus. On systemic examination, the patient was found to have abdominal distension with free fluid. There was no hepatosplenomegaly on per abdomen examination. The patient did not have asterixis and was not in hepatic encephalopathy.

The patient was diagnosed to have severe acute respiratory illness COVID-19 positive (RAT positive) type 2 diabetes, hypertension, and ischemic heart disease status post-PTCA. The patient was started on supplemental oxygen via face mask 4 l/min, IV antibiotics, IV steroids, and other supportive measures according to the national guidelines for COVID-19.

Baseline investigation revealed hemoglobin of 6.8 g/dl, total bilirubin of 2.8 mg/dl, direct bilirubin of 1.3 mg/dl, albumin of 2.3 g/dl, aspartate aminotransferase of 93 U/l, alanine aminotransferase of 45 U/l, prothrombin time (PT) of 16.6, international normalized ratio (INR) of 1.3, and D-dimer of 1050 ng/ml. The patient was considered for initiation of remdesivir therapy, but in view of deranged LFTs, medical gastroenterology opinion was sought, and as per advice, remdesivir was started and daily LFT monitoring was done [Table 1]. Initial chest radiograph revealed left massive effusion with underlying lung collapse with the trachea pushed to the right side [Figure 1].
Table 1: Relevant investigations

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Figure 1: Chest X-ray – On admission (before tapping)

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Chest radiograph was done on admission [Figure 1] and after left-sided thoracentesis revealed partial resolution with respect to degree of effusion [Figure 2]. Ultrasonography (USG) of the abdomen revealed cirrhotic liver disease with reduced portal velocity and gross ascites. The patient was planned for computed tomography (CT) of the thorax; as the patient was not maintaining saturation, it was deferred. USG thorax showed left pleural effusion with underlying lung collapse. Abdominal therapeutic paracentesis done with paracentesis fluid was sent for analysis and was consistent with transudative picture. The patient was given 1 unit of packed red blood cell transfusion. The patient was given fusion 1 unit of albumin infusion in view of hypoalbuminemia. The patient improved symptomatically and CT done later showed ground-glass opacities and consolidation in bilateral lung fields with CT severity score of 4/25 (mild) with bilateral pleural effusion (left > right) with features suggestive of cirrhotic liver disease with gross ascites [Figure 3]. During the course in the hospital, the patient often developed hypoglycemia, for which he was treated accordingly. The patient had a hospital stay for 2 weeks and repeated swab for COVID-19 done before discharge was negative. The patient had improved symptomatically and was discharged and was advised accordingly regarding follow-up. A X-ray was done at the time of discharge (day 14) [Figure 4].
Figure 2: Chest X-ray, day 3, after tapping

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Figure 3: Computed tomography thorax showing ground-glass opacities and consolidation in bilateral lung fields with computed tomography severity score of 4/25 (mild) with bilateral pleural effusion (left > right)

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Figure 4: Chest X-ray – At the time of discharge day 14

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  Discussion Top

The reported prevalence of pleural effusion in COVID-19 pneumonia has been variable in recently published investigations.[18] According to the study by Shi et al.,[19] the prevalence of pleural effusion varies depending on the stage of the disease, with a reported prevalence of 13% in the 3rd week after onset of symptoms. Pleural effusion may also be predictive of a worse prognosis and can indicate bacterial superinfection in COVID-19.[18]

With the worldwide spread of COVID-19, uncommon presentations are still being reported. In our case, all clinical characteristics including signs and symptoms, laboratory investigations, and the results of radiography of the chest suggested COVID-19. The diagnosis was confirmed on COVID-19 RAT. However, pleural effusion, which was diagnosed on radiograph of the chest, is rare in the early phase of the disease.[19] It usually occurs with recurrent pneumonia or after the 3rd week of COVID-19 pneumonia. At this stage, patients are severely sick compared with other patients. A study reported that the percentage of pleural effusion is 8% in patients with mild symptoms compared with 28% in patients critically ill with COVID-19.[17]

Our patient presented with moderate symptoms at an early stage and his medical examination and radiography revealed pleural effusion. Although most patients have mild symptoms and a good prognosis, COVID-19 can develop into severe illness including pneumonia, pulmonary edema, acute respiratory distress syndrome, multiple organ failure, coagulation abnormalities, and even death.

The primary findings of COVID-19 on chest radiograph and CT are those of atypical pneumonia[13],[20] or organizing pneumonia.[21],[22] However, imaging has limited sensitivity for COVID-19, as up to 18% demonstrate normal chest radiographs or CT when mild or early in the disease course, but this decreases to 3% in severe disease.[12],[23] Bilateral and/or multilobar involvement is common.[24],[25]

Chest radiographs may be normal in early/mild disease. In those COVID-19 cases requiring hospitalization, 69% had an abnormal chest radiograph at the initial time of admission, and 80% had radiographic abnormalities sometime during hospitalization.[11] Findings are most extensive about 10–12 days after onset of symptoms.[11] The most frequent findings are airspace opacities, whether described as consolidation or, less commonly, GGO.[11],[12] The distribution is most often bilateral, peripheral, and lower zone predominant.[11],[12] In contrast to parenchymal abnormalities, pleural effusion is rare (3%).[11]

In view of the existing comorbidities, the clinical picture was complicated and contributed for difficulties of diagnosis. Hypoalbuminemia, deranged PT/INR, anemia, and the presence of associated comorbidities are associated with poor prognosis and also pose a challenge in treating these patients; treatment under such circumstances will be based on risk and benefit ratio.

  Conclusion Top

The accurate comment on the prevalence and etiology of pleural effusion in COVID-19 infection should be based on the presence or absence of underlying medical conditions, study setting, disease stage, and concurrent superimposed bacterial pneumonia. Hence, the presence of pleural effusion cannot always be solely attributed to COVID-19 pneumonia.

The coronavirus can have a variety of presentations with unusual radiological findings. Keen clinical judgment with appropriate investigations is mandatory for prompt diagnosis and treatment. Due to the current pandemic situation and the patient was COVID-19 positive and the patient had disproportionate respiratory distress and patient with multiple comorbidities, there was confusion in arriving at diagnosis. However, the superadded COVID-19 infection with preexisting multiple comorbidities in this patient worsened the prognosis and added on to the morbidity. Careful judgment and timely management are approximately necessary and sequential investigation (radiography). High clinical suspicion and ruling out the etiological causes are essential part of the management in multiple comorbidities with COVID-19.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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