Volume 24, Issue 5 (Dec - Jan 2021)                   2021, 24(5): 462-471 | Back to browse issues page

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Zarehoseinzade E, Bijani B, Allami A, Nikoonejad A R, Nazem Sadati S. A Death Case Report in an Adult Woman With COVID-19 after Septoplasty. Journal of Inflammatory Diseases. 2021; 24 (5) :462-471
URL: http://journal.qums.ac.ir/article-1-3132-en.html
1- Deptartment of Infectious Diseases, Clinical Research Development Unit, Bu-Ali Sina Hospital, Qazvin University of Medical of Sciences, Qazvin, Iran.
2- Deptartment of Infectious Diseases, Clinical Research Development Unit, Bu-Ali Sina Hospital, Qazvin University of Medical of Sciences, Qazvin, Iran. , dr.bijani@gmail.com
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1. Introduction
In 2019, a new coronavirus from the family Coronaviridae (Not been seen in humans before) was identified in Wuhan, China, and was named COVID-19 [1, 2]. Due to its higher rate of spread, a pandemic occurred [3]. Its case fatality rate is about 2.2% [4]. This virus is characterized by inflammation of the lungs, formation of ground-glass opacities, acute heart damage (usually in the form of acute myocarditis), and increase in pro-inflammatory cytokines and chemokines in severe cases [5]. Although many factors have been reported as prognostic factors of this disease, identifying all of them requires extensive studies. The main causes of death by COVID-19 pneumonia are the disease itself or complications of the disease. The disease itself, if severe, can cause death due to severe hypoxia and damage to various organs. Its complications leading to death are embolism and thrombosis in the arteries of various organs. Another factor that has been suggested as a risk factor of this disease is severe stress, especially surgery-induced stress Such that elective surgeries in people who were in the incubation period of COVID-19 resulted in mortality rate of about 20-50% [6]. In areas with a high incidence of COVID-19 infection and lack of advanced facilities, the risk and complications of elective surgery outweigh the benefits for both the community and the patient [7]. This case study reports the history and death of an adult woman who underwent septoplasty surgery during asymptomatic COVID-19 infection.

2. Case Report
A 40-year-old woman with no history of previous disease or long-term consumption of certain medication referred to the emergency department of BuAli Sina Hospital in Qazvin, Iran complaining of cough and increased dyspnea for the past two days. She had a history of septoplasty surgery in the past seven days due to a fracture caused by trauma, and discharged two days after the surgery in a good condition and without any postsurgical problem. At the initial examination, the patient was reported to be an adult woman with tachypnea, mild fever (37.5 °C), and low arterial blood oxygen saturation (60%). Other vital signs at the time of admission included a blood pressure of 100/60 mmHg, a heart rate of 90 bpm, and a respiratory rate of 21 bpm. On the Computed Tomography (CT) scan of the chest, bilateral lung parenchyma as patchy ground-glass opacities was observed. At baseline, the white blood cell count was 14,200 per cubic millimeter (91% neutrophils and 6% lymphocytes), the haemoglobin was 13.6 mg/dL, and platelet count was 215,000 per cubic millimeter. The Erythrocyte Sedimentation Rate (ESR) was 50 mm/h and the C Reactive Protein (CRP) level was 43 mg/dL. The serum Lactate Dehydrogenase (LDH) level was 1013 units/L, and the troponin level was 0.006 ng/mL. Echocardiography study showed no abnormality and left ventricular ejection fracture reported was reported 50-55%. 
The patient received supplemental oxygen with a mask with a reservoir bag and was transferred to the Intensive Care Unit (ICU). The patient was treated with lopinavir/ritonavir (Kaletra), ceftriaxone, oral pantoprazole, heparin, and other supportive measures. On the first day of hospitalization (in the morning), remdisivir was prepared and injected. At the same day, patient received a low dose of dexamethasone. Thereafter, ceftriaxone administration was discontinued as imipenem use was started. On the second day (at 2 pm), a sudden respiratory failure occured; hence, the patient was intubated and connected to a ventilator. An hour later, the patient suffered from bradycardia and then cardiac arrest. Despite 45 minutes of cardiopulmonary resuscitation, the patient deceased. After the death, the real time polymerase chain reaction test result, taken from the sputum sample at the time of admission, was positive for COVID-19.

3. Discussion and Conclusion
Infection with COVID-19, even in the intubation period, can negatively affect the prognosis of surgery [6]. In the reported patient, there was no evidence of surgical site complications related to surgery or anaesthesia, and infection with COVID-19 can be considered as the main cause of death. In a cohort study in China, it was reported that being in the intubation period of COVID-19 infection increase the need for admission to the Intensive Care Unit (ICU) in a postoperative period from 26.1% to 44.1% [6]. In this study, most of the patients who needed admission to the ICU had risk factors such as old age or underlying cardiopulmonary and metabolic diseases. In the mentioned study, the severity and length of the surgery also increased the risk of hospitalization in the ICU. These problems were not present in our patient. Many studies suggest that the stress induced by surgery itself is an important factor worsening the prognosis of COVID-19 infection. Surgery has adverse negative effect on the immune system function in the postoperative period [8]. On the other hand, surgery can be associated with a severe inflammatory response and cause serious complications in patients with mild COVID-19 or even those who are in the intubation period. 
Due to the lack of medical history and underlying problems related to the prognosis of COVID-19 patients (e.g. history of hypertension, diabetes, cancer, and immune system deficiency) and the confirmed negative effect of surgery-induced stress on the immune system function, the surgery-induced stress can be considered an important factor for the unfavorable prognosis of COVID-19 infection in the study patient. Therefore, as long as the pandemic continues, the surgery risk should be taken seriously in planning for elective surgeries [10]. Despite the introduction of several drugs for the treatment of COVID-19, they have not had a significant and proven effect on the disease. Hence, it seems that the most effective measure to prevent severe complications of COVID-19 infection in surgical patients is to avoid elective surgery, especially in patient with subtle respiratory symptoms [11].

Ethical Considerations
Compliance with ethical guidelines

Ethical principles were observed by providing explanations to the patient and obtaining her informed consent to participate in the study, and assuring her of the confidentiality of her information. The ethical approval was obtained from the Research Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1399.180)

This research received funding from the Bu-Ali Sina Hospital in Qazvin, Iran

Authors' contributions
Gathering information, participating in the case report: Elham Zare Hosseinzadeh; Introducing the sample, following up the client's treatment, supervising and managing the project, searching and translating articles: Behzad Bijani; writing, typing and editing, resources: Abbas Alami; Conceptualization and data collection: Ali Reza Niknejad and Sara Nazem Sadati.

Conflict of interest
The authors declare no conflict of interest.

The authors would like to thank the Clinical Research Center and the Research Committee of BuAli Sina Hospital.

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Type of Study: Case report | Subject: Infectious Disease

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