A 20-year-old previously healthy gravida (G1P1) was referred with sever vulvar pain and edema (Fig. 1) on the 7th day after her labor. The past medical history of the patient showed no presence of anemia (Hb: 13.3, HCT: 39.2, BGRH: B+) high blood pressure, malnutrition, hemoglobinopathies, lower limb edema , or any complications such as symptoms of covid-19. She gave a normal vaginal delivery with restrictive episiotomy incision at 40 weeks of gestation 7 days before the admission without any complication. After that, she experienced mild vulvar edema by passing 12 h from labor. Thereafter, she was hospitalized for 2 days. She was then discharged with the administration of some medications including Acetaminophen, Cefixime, Metronidazole, and Enoxaparin, and by considering that no basic cause was found for her vulvar edema.
Four days after discharge, the patient came back to the hospital with the chief complain of sever vulvar edema (Fig. 1). Subsequently, the vital signs showed hypothermia and bradycardia (T: 35.5, PR: 56. BP: 120/70, RR: 24 & SPO2:97%). The patient also had an ill and dehydrated appearance, anorexia, and oliguria accompanied by mild nausea in the last few days. The patient reported no symptoms of respiratory disease. She was then hospitalized with the initial diagnosis of necrotizing fasciitis or cellulitis.
The clinical examination indicated severe and uncommon edema in the hypogastric region spreading to the perineal and gluteal regions (Based on the image shown in Fig. 1) with tenderness and exudative discharge; however, the episiotomy incision had a normal appearance. The spiral Lung HRCT , as well as Spiral CT of the abdomen and pelvis , werewas requested to examine the subcutaneous emphysema and the necrotizing fasciitis. In CT of the abdomen and pelvis, there were edema and stranding in the subcutaneous soft tissue of the hypogastric region, preferably in the pelvis, free fluid in the abdomen, and stranding in the pelvis. In HRCT multiple bilateral, multi -lobar, peripheral, and round ground -glass opacities were seen. Altogether, these findings were highly suggestive for Covid-19 pneumonia (typical appearance) (Fig. 2).
The antibiotic regimen of Meropenem and Vancomycin, azithromycin and Caletra (Lopinavir & Ritonavir), and Hydroxychloroquine were added to the patient’s medication regimen due to the high prevalence of coronavirus in society and hospital.
On the same day, the patient was transferred to the operating room with the possibility of necrotizing fasciitis. Thereafter, to overcome the oliguria, the CVL was installed for the patient in the operating room. Edematous and thick perineal skin debridement was performed and a clear, non-purulent transudate was removed from the cutaneous and subcutaneous tissues. Moreover, a sample was sent for culture and antibiogram and based on the obtained results, the possibility of necrotizing fasciitis was rejected by the surgeon, due to tachycardia and rhythm 130, the echocardiography was ordered in bed, which consequently resulted in the systolic dysfunction (EF = 40%), global hypokinesis, and mild hypertrophy of the left ventricle.
Due to positive RTPCR testing for covid-19, leukocytosis, the initial NLR > 3.5 and CRP = 78 mg/L, and the Lung HRCT report, the patient was quickly sent to the isolated ICU with the suspected pneumonia of Covid-19 and sepsis. Despite sustainable vital signs, diuresis, and normal Oxygen saturation, the patient had mild respiratory distress. Repeated tests indicated hypoalbuminemia, higher INR, thrombocytopenia, leukocytosis, severe lymphopenia, greater lactate dehydrogenase, hyperbilirubinemia, metabolic acidosis, and progressive hepatocellular damage. Afterward, the hematologists checked the peripheral blood smear, excluded leukemia, and finally confirmed the leukemoid reaction. Notably, the patient was severely dehydrated. In addition, the results of repeated laboratory tests showed sever leukocytosis and hemoconcentration. Accordingly, C Albumin was prescribed to correct the condition.
On the morning of the next day, the patient’s respiratory problems increased and the oxygen saturation level decreased from 97 to 87%. Four hours later, the patient had apnea, so she was immediately intubated and connected to a ventilator. Mydriasis was doubled at the same time, and Epinephrine drip continued for her. An hour later, she underwent CPR due to hemodynamic disorder, respiratory arrest, and bradycardia. Finally, she was expired because of respiratory distress after 33 h of hospitalization.