Lessons Learnt from the Management of Severe COVID-19 Disease in a 93-year-old with Chronic Co-Morbidities at a Resource-constrained Centre in Nigeria – A Retrospective Single Case Study

Abstract

Introduction: Severe COVID-19 infection is associated with significant mortality in the elderly. This is even more so, when the elderly patient with the disease also has multiple chronic co-morbidities, and is resident in a resource-constrained area. Aims/ Objectives: To outline management strategies employed, and important lessons learnt from the successful management of a case of severe COVID-19 disease in a 93-year-old with chronic co-morbidities in a resource-limited setting. Methods: We utilized a simple COVID-19 severity categorization algorithm on presentation, to assign the index patient to the appropriate COVID-19 disease severity class and subsequently employed patient’s serial, weekly clinical and laboratory parameters to guide a multi-specialty management protocol. Results: A 93-year-old man was referred to a tertiary hospital in Enugu during the second wave of the COVID-19 pandemic, with a 5-day-history of high grade fever, severe fatigue, and altered sensorium. He had been living with diabetes for 48years; recently had worsening glycemic control, and was yet to pass urine in the previous 12hours. He was also being managed conservatively for prostate carcinoma. Examination revealed signs of severe pneumonia and he was drowsy, dehydrated, and had asterixis. A diagnosis of acute kidney injury from septicemia, following community acquired pneumonia and possibly urinary tract infection was made, with COVID-19 infection as a differential. Samples were collected for laboratory investigations while he was recommended for intensive care unit admission for further care. Para-enteral broad spectrum antibiotics, intravenous fluid therapy, intranasal oxygen therapy, basal-bolus-insulin-regimen, and anti-coagulation prophylaxis were instituted. Following laboratory investigation results which included a positive COVID-19 test (clinically categorized as severe disease), severe systemic inflammation, evidence of uro-tract infection, intravascular thrombosis and severe renal impairment, the Nephrology, Infectious disease, Urology teams were invited to co-manage the patient alongside the Endocrinologists. After 27days of collaborative care, patient was discharged with resolution of his symptoms and signs. Conclusion: Multi-specialty collaborative care improves patients’ outcome even in the face of severe COVID-19 with associated co-morbidities in elderly patients. Severity stratification ensures life-saving timely care for severe COVID-19 disease.