Determining New Onset Pulmonary Involvement of Connective Tissue Disease in a Patient with Recently Diagnosed Coronavirus Disease 2019

Abstract

A 49-year-old female presented due to sore throat, productive cough, fever, shortness of breath with a past medical history significant for COVID-19 infection in 04/20, nonsmoker, NSTEMI and diabetes mellitus type 2. On admission, labs revealed leukocytosis 16.33 K/mcL with left shift, D-dimer 9660 ngFEU/mL, elevated troponin x 3, lactic acid 2.4 mmol/L. Repeat COVID-19 test was negative on 05/20. Patient had an abnormal chest CT with diffuse ground glass opacities which is compatible with COVID-19 related post infectious inflammation. HIV panel and respiratory viral panel were negative. Due to elevated troponins with wall motion abnormalities patient underwent cardiac catheterization which revealed no obstructive coronary artery disease however right ventricular dysfunction was noted with elevated right ventricle (44 mmhg) and right atrium pressures (42 mmhg), normal pulmonary capillary wedge pressure. RV dysfunction was likely related to post COVID myocarditis/hypoxemic respiratory failure. Patient was discharged home on a course of prolonged steroid taper and 3-4 L oxygen. Four months later in 09/20 the patient again presented with similar complaints of shortness of breath and chest pain. Due to an elevated D-dimer and tachycardia, a CTA was obtained which was negative for pulmonary embolism however showed diffuse ground glass opacities which appeared to be persistent;distribution attenuation was also similar to previous study with worsening basilar regions concerning for consolidation. Laboratory studies in 09/2020 remarkable for leukocytosis with left shift, elevated troponin and total CK, urine toxicology was negative. Patient completed treatment for CAP on both admissions with no significant improvement. Routine immunology workup positive for ANA, speckled pattern with titer greater than 1:1280, serial rheumatoid factor 336.5 Lunits/ml, RNP antibody greater than 8 Al, SmRNP antibodies > 8.0 Al. All other immunologic workup were negative and the patient had no signs of rheumatologic conditions. Patient was started on a prolonged steroid course due to concern for superimposed mixed connective tissue disease (MCTD) pulmonary involvement with underlying CT manifestation of COVID 19, which drastically reduced her oxygen requirement. Chest CT images in patients with underlying COVID-19 infection can resemble and obscure new onset rheumatologic conditions with pulmonary involvement, such as mixed connective tissue disease, systemic lupus erythematosus, rheumatoid arthritis and hence it may delay the diagnosis of progressive pulmonary conditions which require prompt treatment. CTA on 09/20 (right) on admission showing bilateral diffuse ground glass opacities throughout the lung parenchyma with predominantly dense lower lobe opacities and mild air bronchogram (Left 05/20).