A 76-year-old man admitted 12 days ago to hospital with increased confusion and reduced mobility. He had a history of Parkinson’s disease and early Parkinson’s dementia but generally could function reasonably well and was able to attend to some of his activities of daily living.

On admission his blood showed normal white cell count and C reactive protein with normal kidney and liver function tests. His initial Chest X-ray reported as normal. A differential of a urinary tract infection and or increased confusion due to Parkinson’s disease medications causing delirium was considered.

Over the next 10 days his parkinson’s medications were adjusted. He was monitored for any signs and symptoms of infection. He was managed in a normal bay and continued with physiotherapy who told he was far away from the normal baseline. 

On the 10th day he became unwell with shortness of breath and some left sided crackles on auscultations. A possibility of hospital acquired pneumonia was considered and intravenous tazocin was prescribed. A repeat chest X-Ray carried out but did not show convincing evidence of an infection.

He was desaturating and as he had refused to have prophylactic clexane, a CT pulmonary angiogram was performed to check whether he had developed pulmonary embolism. The CT showed bilateral pneumonic changes. Covid -19 PCR testing was sent which came back as positive. The patient deteriorated rapidly and passed away on the 14 days after admission.

 

CT PA showing bilateral pneumonic changes

 

His full blood count on admission showed Hb 88 g.l, WCC 4.3, neutrophils 3.3. The lymphocyte count however, was low at 0.8 (normal 1—3). Lymphopenia appears to be a consistent feature in Covid-19 infection. 

In normal day today practice, routinely we do not pay much attention to lymphocyte count in the full blood count. In this case, it is right to consider possible UTI or medications for delirium as these are common causes in an elderly Parkinson patient.

However, currently Covid-19 infection is possibly the most common infection and it is important to consider this as a possible differential and to look for any associated features in every patient coming to hospitals. If we had thought about possible Covid-19 infection at the beginning, we would have looked at the lymphocyte count, isolated the patient and tested early for Covid-19 infection. This is a new disease and we all are learning as we go.

 


Dr Nishantha Silva – Consultant Physician and Geriatrician, Clinical Lead for Parkinson’s Disease, Sherwood Forest Hospitals NHS Foundation Trust- Nishantha.silva@nhs.net

Dr Slavka Ulikova – Consultant in Geriatric medicine, Sherwood Forest Hospitals NHS Foundation Trust - slavka.ulikova@nhs.net

Dr Mohdanas Aishah, Specially Registrar in Geriatric, Sherwood Forest Hospitals NHS Foundation Trust - sitiaishah.mohdanas@nhs.net