Coronavirus disease 2019 (COVID-19) is an acute respiratory tract disease caused by severe acute respiratory syndrome coronavirus 2 that was first identified in Wuhan, China, in December 2019 and has spread globally.1 As of February 17, 2021, more than 110 million cases have been reported worldwide with more than 2 million deaths.2 This disease causes a wide range of symptoms from mild headache, cough, and diarrhea to severe shortness of breath, fevers, and acute respiratory failure requiring admittance to an intensive care unit leading to intubation and mechanical ventilation.3 The mortality rate for individuals with comorbidities is substantially elevated as compared with individuals with no comorbidities as seen in an epidemiological study from China.4
Given the unpredictable and potentially fatal course of this disease, prompt diagnosis in the spinal cord injury (SCI) population is essential. Although coughing is the second most common presenting symptom in the general population, tetraplegics and high paraplegic patients may not have the ability to mount a cough. Therefore, this criterion does not satisfy traditional algorithms for diagnosing COVID-19. Righi and Del Popolo5 (2020) published a case report from Italy documenting a patient with chronic tetraplegia who developed COVID-19 without symptoms of a cough. A seven-patient cohort study from Spain in May 2020 documented the clinical and analytical presentation of COVID-19 in individuals with SCI in a long-term healthcare facility.6 Fever was the most common initial sign at the time of diagnosis. Most patients in this study had a subacute sensorimotor complete SCI. Furthermore, there is a case report showcasing COVID-19 in a patient with an acute SCI involving the cervical spine who presented with cervical muscle pain and then developed a fever before he was diagnosed with COVID-19.7 Our case report is the first to identify COVID-19 in an acute motor incomplete SCI in an inpatient rehabilitation (IPR) setting.
A 32-yr-old man with no significant medical history presented to the acute trauma hospital in early March 2020 after falling down a flight of stairs while inebriated. He was noted to have decreased sensation in all limbs with limited movement of his upper limbs and inability to move his lower limbs. Computed tomography imaging revealed bilateral facet dislocation and fractures at cervical spine levels 6–7. After neurosurgical consultation, he was given a loading dose of dexamethasone and then underwent emergent anterior cervical discectomy and arthrodesis at C6–7, posterolateral arthrodesis at C4–5, C5–6, C6–7, and decompressive laminectomy from C5 to C7.
He was successfully extubated postoperatively without the need for prolonged ventilation. He was evaluated by speech therapy and started on a regular diet. Although he did not require pressor support while in the intensive care unit, he later developed hypotension in the surgical step-down unit with systolic blood pressures in the 90s mm Hg with initiation of midodrine 3 times a day to maintain his mean arterial pressure of greater than 85 mm Hg.
Eight days after the neurosurgical procedure, he developed acute onset swelling in the bilateral lower limbs and was found to have a deep vein thrombosis in the right femoral vein proximal and distal to the knee as well as a deep vein thrombosis in the left leg distal to the knee in the left infrageniculate vein. Neurosurgery did not clear him for oral anticoagulation given the recent surgery, and thus, an inferior vena cava filter was placed.
Although he was weaned off dexamethasone, he did develop leukocytosis as high as 16,100/mm3 in the acute trauma hospital, which decreased to 8400 cm3 when he was discharged to an IPR facility. During this time, he remained afebrile and did not complain of any cough, shortness of breath, or hypoxia. Multiple chest x-rays taken in the intensive care unit remained negative for any acute cardiopulmonary process.
In late March 2020, he transferred to IPR for further care. In the initial assessment, his International Standard for the Neurological Classification of Spinal Cord Injury examination categorized him as a C4 American Spinal cord Injury Association Impairment Scale D traumatic motor incomplete tetraparesis.
On the second day of admission, he became febrile to 39.3°C and began to experience nasal congestion. A full infectious workup, including lactic acid, urinalysis, comprehensive metabolic panel, and complete blood cell count, ferritin, lactic dehydrogenase, influenza A/B and respiratory syncytial virus panel, and blood cultures were all negative. A chest x-ray film revealed clear lung fields with no evidence of infiltrates or opacities (Fig. 1). He was tested for influenza and respiratory syncytial virus and placed under contact and droplet precautions. Despite negative initial workup, he continued to have temperatures at or greater than 38°C, whereas blood pressure, heart rate, respiratory rate, and oxygen saturation remained within normal limits.
The infectious disease team was consulted and determined that he did not meet criteria for COVID-19 testing given his lack of respiratory symptoms. Additional workup, including venous duplex ultrasound of bilateral upper and lower limbs, was completed and negative. The deep vein thromboses observed previously in the acute trauma hospital were no longer present.
Because of the emerging COVID-19 crisis in the state of Michigan at this time, the Health Department was contacted for further recommendations and the decision was made to collect a sample for testing via a nasopharyngeal swab for reverse transcriptase–polymerase chain reaction testing. The sample was sent to another testing facility as the hospital was not equipped with in-house testing at that time. Fifteen days later, the results returned positive for the virus and the patient became the first positive case at the IPR facility. His clinical course of elevated temperatures and the relevant clinical decision-making information is outlined in Figure 2. He developed an elevated temperature on his first day of IPR and then another 48 hours later and then remained afebrile afterward.
Throughout his stay at the IPR facility, he did not develop any other symptoms, such as cough, shortness of breath, or hypoxia. Given his asymptomatic clinical status and isolation precautions limiting therapy, a repeat COVID-19 nasopharyngeal swab was taken on his 26th day of IPR. At this time, the hospital was performing in-house testing, and after 24 hrs, the severe acute respiratory syndrome coronavirus 2 nucleic acid test resulted negative. Infectious disease recommended discontinuing isolation precautions as he was asymptomatic for 23 days. The patient was safely discharged home 3 wks later after 46 days in the IPR facility.
A large, retrospective cohort study of 191 patients conducted in Wuhan, China, found that 94% of patients with COVID-19 initially presented with a fever, and of those, 79% also presented with a dry cough. These patients developed elevated inflammatory markers, including lactic dehydrogenase and ferritin within 4 days of symptom onset and levels that remained elevated after 25 days. Patients were also seen to have chest x-ray findings consistent with bilateral pulmonary infiltrates.8
In contrast to this cohort study from China, the patient in our case report only presented with a high-grade fever of 39.3°C. Furthermore, although he tested positive for COVID-19, he did not mount a significant immune response, as laboratory analysis did not demonstrate leukocytosis or elevated inflammatory markers. Moreover, no radiographic evidence of the bilateral opacities that are classic for COVID-19 was found.
Although the general COVID-19 population presents with a fever and a cough, patients with SCI may present differently because of their injury. Patients with higher level SCI (C2–T4) are limited in their ability to cough without external assistance because of paralysis of diaphragm, abdominal, and/or intercostal muscles.9 Patients may only present with a fever and not develop the other symptomatology of this viral disease. Moreover, individuals with cervical cord injuries have a restrictive respiratory dysfunction with reduced expiratory reserve volume, vital capacity, inspiration capacity, and total lung capacity.10 With such a reduced lung function, these patients are at risk for respiratory infections and pulmonary compromise.
In addition, patients with SCI may have an altered immune response after the injury. Natural killer cells are lymphocytes that spontaneously attack and lyse foreign cells in the body, including tumor and virus-infected cells.11 Campagnolo et al.12 (2008) published a cross-sectional, paired cohort study examining the number and cytotoxicity of nature killer in patients with SCI compared with noninjured subjects. Patients with SCI, regardless of their neurological level of injury, had a significant reduction in the number of natural killer cells as well as decreased cytotoxicity in terms of a smaller percentage of lyses by natural killer cells. These findings reveal that as a result of their limited ability to respond to foreign antigens with their innate immune system, patients with SCI are highly susceptible to infections, such as COVID-19.
Because of their limited capability to mount an adequate immune response, patients with SCI are more vulnerable to infections, especially during the current COVID-19 pandemic. It is paramount to ensure that individuals with SCI are monitored regularly in an IPR facility to ensure their health and safety. When caring for patients with SCI, physiatrists need to be vigilant and monitor symptoms, such as a fever, as that may be the only presenting symptom leading to diagnosis of COVID-19 in these patients. Moreover, the threshold to test for COVID-19 may need to be decreased and seriously considered when a patient with SCI develops a fever to prevent a delay in diagnosis and potential exposure to other patients.
As COVID-19 is an uncharted illness and its far-reaching effects have yet to be determined, extreme caution must be practiced when taking care of patients, especially those with spinal cord injuries. Patients at risk for cardiopulmonary distress with impaired lung volumes and respiratory reserve need close monitoring of respiratory symptoms and development of fevers. Individuals with an acute to subacute SCI who are transferred to an IPR facility from acute care hospitals may have a milder presentation of COVID-19, leading to a delay in testing and diagnosis and increasing the potential for exposure to other vulnerable patients. Thus, in the unique SCI population, having a higher suspicion for COVID-19 despite a lack of symptoms beyond a fever may be necessary to care for these patients. This case demonstrates COVID-19 in a patient with an acute motor incomplete SCI whose only complaint was a fever. Physiatrists need to be aware of this manifestation of the COVID-19 virus in patients with SCI to provide safe and effective care during the current pandemic.
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