key: cord-270897-fywmv7jg authors: Pattanakuhar, Sintip; Tangvinit, Chatchai; Kovindha, Apichana title: A Patient with Acute Cervical Cord Injury and COVID-19: A First Case Report date: 2020-06-01 journal: Am J Phys Med Rehabil DOI: 10.1097/phm.0000000000001485 sha: doc_id: 270897 cord_uid: fywmv7jg During the pandemic of Coronavirus disease 2019 (COVID-19), it is possible for rehabilitation physicians and personnel to take care of patients with concurrent spinal cord injury (SCI) and COVID-19. Here, we describe a case of acute cervical SCI resulting in complete tetraplegia C5 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A with unrecognized, acute respiratory syndrome coronavirus 2 (SAR-CoV-2) infection. This resulted in large-scale quarantines of related surgical and rehabilitation staff, and the unexpected death of the patient despite receiving the treatments according to the standard guideline. Rehabilitation personnel who take care of acute SCI patients with COVID-19 should consider the effect of SCI on the course of COVID-19, the effect of COVID-19 and its treatments on the course of SCI, and risks of SAR-CoV2 transmission between patients and rehabilitation staff, to continue providing safe and effective rehabilitation programs. Acute cervical spinal cord injury (SCI) is a severe, life-threatening condition causing functional impairments and affects multiple body systems including the respiratory system. 1 Coronavirus disease 2019 (COVID-19) resulting from severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2) infection, which is currently pandemic, also causes severe respiratory problems 2 . In this case report, we present a patient who had these two devastating health conditions concurrently, resulting in catastrophic consequences to both the patient and related healthcare staff. (PUI) would be indicated if the patient had both history of exposure and symptoms consistent with COVID-19. Since no information regarding exposure and no respiratory tract symptom was detected, the patient was not included in the PUI group on admission. Ten hours after injury, anterior cervical discectomy, and fusion with plates and screws and iliac bone grafting were performed. An endotracheal tube was immediately removed after the operation, and no immediate post-operative respiratory complication was detected. On day 2 of admission, he was transferred to an orthopedic ward and a rehabilitation physician was consulted to prevent complications and maximize his function. Daily subcutaneous injection of 0.6 ml (60 mg) of enoxaparin was initiated for venous thromboembolism (VTE) prophylaxis. No mechanical prophylaxis of VTE was applied. The rehabilitation program consisted of range of motion and isometric strengthening exercises of bilateral elbow flexors was provided at the bedside. On day 3 post-SCI, he complained of muscle pain in the neck and both shoulders and presented with low-grade fever, 37.8 °C. Acetaminophen was prescribed as a symptomatic treatment of fever. On day 4, it was the first time the possibility of COVID-19 was considered as his friend told that he stayed in an epidemic area of COVID-19 for two weeks before the accident. A nasal swab was done and the SAR-CoV2 RNA was identified with reverse transcriptase-polymerase chain reaction (RT-PCR) technique. The patient was then transferred to the COVID-19 cohort ward. Also, droplet precautions were applied. All related hospital staff Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. results were negative in all tested personnel. However, 104 hospital personnel had to be quarantined because of having close contact with the patient. Oral hydroxychloroquine and azithromycin were administrated according to the local COVID-19 treatment guideline. On day 6, the patient developed high-grade fever, 39°C with mild dyspnea. The chest xray revealed mild thickening of left lower lung marking ( Figure 1 ). performed in this case due to safety and resource preservation issues during the COVID-19 epidemic period. To our knowledge, this is the first case report describing COVID-19 in a patient with acute SCI. Although the exact cause of death in this patient has not been proven, which is the main limitation of this report, the differential diagnosis leading to death in this case is important to consider. The most common cause of death in patients with COVID-19 is reported to be acute respiratory distress syndrome (ARDS). 2,4 ARDS in COVID-19 is a result of severe COVID-19 pneumonia, indicated by definite pulmonary infiltration and severe hypoxemia. However, none of these findings were found in this patient. The characteristics of death in this patient were acute, unexpected cardiac arrest, or sudden death. 5 Sudden cardiac death is commonly due to ventricular arrhythmias. 5 The causes of ventricular arrhythmias in this patient could be divided into COVID-19 and non-COVID-19 related conditions. The COVID-19 related conditions are viral myocardial injury, 6,7 cardiac tamponade 8 , and torsade de pointes from an underlying long QT syndrome superimposed by hydroxychloroquine and azithromycin use. 9, 10 In this patient, myocarditis and cardiac tamponade are less likely since there were no symptom of severe dyspnea. Although torsade de pointes could not be ruled out since it could induce a sudden death without a prodromal symptom of dyspnea, it is less likely to be the cause of death since the ECG of the patient did not show a long QT interval. A non-COVID-19 related cause of cardiac sudden death in this patient could be pulmonary embolism (PE), 5 which is commonly found in patients with acute SCI. 11,12 PE seems to be less likely as this patient had received the prophylactic dosage of enoxaparin when the Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. sudden death occurred. However, PE could still develop since this prophylactic dosage is lower than the treatment protocol for VTE. 11 Another possible cause of sudden death in cervical SCI patients is secretion obstruction from an inability to effectively produce cough. 13 Therefore, patients with acute SCI and concomitant disease of COVID-19 might be in the highest risk of developing VTE, including PE, which could be one of the suspected causes of sudden death in this patient, despite routine prophylaxis as PE should be a differential diagnosis in all acute SCI patients who abruptly develop dyspnea or in a severe case with a sudden loss of consciousness, regardless of COVID-19. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. The second issue to consider is the effect of SCI on the clinical course of COVID-19. Cervical cord injury results in weakness or paralysis of extremities and trunk muscles, including respiratory muscles such as intercostal, pectoral, abdominal, or even diaphragmatic muscles. This respiratory muscle function impairment change reduces the vital capacity of the patient's lungs and decreases the ability to cough effectively. 13 In conclusion, during this COVID-19 epidemic period, acute SCI patients could have concurrent COVID-19. Therefore, rehabilitation personnel who take care of acute SCI patients with COVID-19 should always consider the effect of SCI on the course of COVID-19, the effect of COVID-19 and its treatment on the course of SCI, and risks of SAR-CoV2 transmission between patients and rehabilitation staffs, to continue providing safe and effective rehabilitation programs. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Respiratory dysfunction and management in spinal cord injury. Respiratory care Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. The New England journal of medicine Clinical practice guidelines for diagnosis, treatment and prevention of cornona virus disease 2019 (COVID-19) Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study Sudden Cardiac Death: Who Is at Risk? The Medical clinics of North America Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19) Association of Cardiac Injury With Mortality in Hospitalized An algorithm for managing QT prolongation in Coronavirus Disease 2019 (COVID-19) patients treated with either chloroquine or hydroxychloroquine in conjunction with azithromycin: Possible benefits of intravenous lidocaine SARS-CoV-2, COVID-19 and inherited arrhythmia syndromes. Heart rhythm Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guidelines for Health Care Providers Pulmonary embolism after manual muscle testing in an incomplete paraplegic patient: a case report Respiratory management in the patient with spinal cord injury Alterations in cardiac autonomic control in spinal cord injury