4.1. Diagnoses Backed up by Medical Specialists
Laboratory findings are shown in Table 3
; chronic and acute conditions are highlighted (in bold for chronic and bold and italics for acute conditions).
Type 2 diabetes mellitus derailed with diabetic nephropathy
Acute bronchitis in COVID (SARS-CoV2 positive)
Progressive aortic stenosis
Chronic renal failure CKD 4
Other spondylosis with radiculopathy: lumbar region with secured neuroforamen stenosis on the right L4/L5
Gonarthrosis on both sides
Knee replacement on the right
Gastrointestinal bleeding 09/2016
Chronic heart failure NYHA (New York Heart Association) 2
Fall tendency with difficulty walking
The multimorbid patient (84 years old) was hospitalized because his general condition was deteriorating. He reported fatigue and feeling unwell. The patient complained of general weakness and worsening drowsiness in the last 15 days. He was tired and listless. Prior to that, he had had fever up to 38 °C and a dry cough. His fever had been dropping for about 3–4 days before he was admitted to the hospital. He had been coughing mainly during the day. His throat had also been uncomfortably sore, and his appetite had decreased. Clinically, the patient was dehydrated on admission. However, he reported that he had been drinking sufficient amounts of fluids.
The patient had not been taking antibiotics earlier on. He had had no sniffles, and his sense of taste had not changed. One of his relatives had a cold, and another one had pneumonia.
The patient presented with fissured tongue and dry skin. A PCR test for SARS-CoV-2 had not been performed in advance.
The patient had had insulin-dependent type 2 diabetes mellitus for several years. In the previous 2 weeks, his blood glucose values had indicated hyperglycemia. His ICT insulin regimen had been adjusted about 5–6 months before (Levemir (Insulin Detemir) 26 IU at 10 pm and Apidra (Antidiabetic drug) with meals).
One week before admission, the patient had consulted a dermatologist for acute urticaria of unknown etiology. According to the patient’s medical history, he has had no known allergies. The patient received 100 mg Solu-Decortin (Natrium (prednisolon-21-succinat) and 8 mg IV Dimetinden (H1 antihistamines). The dermatologist prescribed a cortisone pulse therapy with 10 mg prednisolone in the morning for 5 days, and 10 mg/day of cetirizine. The patient’s blood glucose levels rose significantly under cortisone therapy and infection. He had hypoglycemia early in the morning and hyperglycemia up to 500–600 mg% during the day. Hypoglycemia caused the patient to sweat profusely. He did not report nausea, vomiting, or diarrhea. He reported having spent the previous week mostly in bed with fatigue and listlessness.
The patient has also had chronic NYHA 2 heart failure for several years. In the previous 4 days, he had noticed dyspnea, even on light exertion, when performing day-to-day activities at home.
On admission, the patient also complained about immobilizing knee pain. He had had a known chronic pain syndrome with back and joint pain. His back pain had been treated with pregabalin (Lyrica®) and metamizole (dipyrone) for several years. He had been taking 10 mg Doxepin at night to calm down and to relieve anxiety.
Self-reported history: symptoms of an upper respiratory tract infection for about 10 days, which had been treated for 2–3 days with acetylcysteine on an outpatient basis. Pulmonary symptoms: low-grade anthracofibrosis, which had been diagnosed two years before. Cortisone pulse therapy for spontaneous urticaria, with the resulting hyperglycemia, one day prior to the admission.
History of the autonomic nervous system: somnolence. No nicotine. Appetite significantly reduced. No known allergies. Voiding normal; nocturia 2x. Bowel movements: constipation. Height: 180 cm. Weight: 83 kg.
4.2. Treatment, Clinical Course, and Results
The patient was admitted to the hospital with a pronounced deterioration of his general condition. He was feeling unwell, was dehydrated, and complained of fatigue. He had had fever and a severe dry cough for 3–4 days before admission. At the time of admission, the patient’s physical functions were severely limited with a score of 8% (Hannover Functional Questionnaire). The standard value is 77%. On the day of the admission, the patient was tested for SARS-CoV-2 RNA due to his general condition and his self-reported medical history. He was then isolated according to the requirements of procedure 8–98 g.01.
The initial test result for SARS-CoV-2 RNA on April 6th was negative. In line with the guidelines, the patient was tested again on the second day after admission (thus, 7 April), following World Health Organization protocols (WHO 13.03.20). For both tests, a reverse transcription polymerase chain reaction test was administered. On 7 April, the test result was positive. The patient was reported to the relevant Health Department, and category A contact persons, who in this case were relatives who had had direct contact with the patient, were advised to self-isolate.
Immediately after the admission, we started an empirical IV treatment with Sterofundin and Cernevit (Multivitamin supplement). We carefully restored the patient’s fluid balance and started his mobilization early on. The patient was treated with frequent sessions of physiotherapy and manual therapy. He also received daily massage sessions with Vibrax and Tri-Flow therapy to stimulate his breathing. We performed an inhalation therapy with PARI BOY NaCl 0.9% (1 ampoule of Atrovent (Ipratropiumbromid), 15 drops, and Salbutamol (β₂-Sympathomimetikum), 15 drops, 3 times a day), as well as frequent rubbing with aconite oil to stimulate breathing. We also applied oxygen therapy since the patient’s spontaneous oxygen saturation was reduced to 88% on admission. The patient was administered O2 at 2 L/min. He did not require supplementary oxygen afterwards, and his respiratory function stabilized. His cough continued to abate, and his breathing became easier with time.
The symptoms of the patient were markedly relieved following frequent mobilization measures and breathing exercises. His dyspnea on light exertion was in remission. His inflammation parameters, which had been elevated initially, also fell over time. Initially, the patient’s renal function parameters had been out of range due to dehydration. They markedly improved over the course of the empirical IV therapy. Blood platelet count was Tsd/µL 337 at admission and 266 at discharge.
His blood glucose levels were highly elevated, and he had hyperglycemia at 405 mg% (equaling 22.48 mmol/L; thus, a reduction of 295 mg/dL would be required to reach normal levels) in the context of his type 2 diabetes mellitus, which had been known for years. The intensive conventional insulin therapy was optimized over time under close blood sugar monitoring, which was performed daily at 07:00 a.m., 11:00 a.m., 02:00 p.m., 05:00 p.m., 10:00 p.m., and 02:00 a.m. (with values ˃ 300 mg%, we performed the measurements every half an hour). We set the long-acting insulin (detemir) to 24 IU, and the patient was taking the rapid-acting insulin (apidra) with meals at increased doses. In terms of nutritional measures, the patient was following a special dietary regimen. His blood sugar levels were satisfactory on discharge.
The isolated urticaria of unclear etiology may have been caused by analgesia with metamizole (Novalgin®), which the patient had been using for weeks. We changed the analgesia to naproxen ((S)-2-(6-Methoxy-2-naphthyl) propionsäure) with a dosage of 250 mg (2–3 times a day as required). The patient also received treatment with alpha lipoic acid at 600 mg/day for suspected diabetic polyneuropathy. His pain, which had been between 6 and 7/10 on the Visual Analogue Scale on admission, was also alleviated thanks to all the therapeutic measures.
After the eight-day hospitalization with frequent application of the above-mentioned measures and implementation of the complex treatment OPS 8–98 g.01 (Table 4
), the patient was discharged into home isolation (quarantine). There were no complications. Thus, the patient’s primary care giver (daughter) was asked upon discharge to call immediately in case of a deterioration in the patient’s condition. This has not happened so far (status: January 2021).