A previously healthy 21-year-old Caucasian man was admitted for vasoplegic shock. He denied any drug intake, did not smoke tobacco, or use illicit drugs. He presented with a fever of 39°C (102.2°F) with chest tightness, nonbloody watery diarrhea lasting for 7 days, and a rash that had developed over 3 days. On clinical examination, he was febrile (40°C [104°F]), blood pressure was 80/40 mm Hg, respiratory rate was 38 breaths/min, and oxygen saturation was 97% on ambient air. An asymptomatic rash was present over his trunk and palms, consisting of erythematous round-shaped macules with a darker and raised rim, 1-3 cm in diameter, along with bilateral conjunctivitis (Figure 1). The white cell count was 16,000/mm3, with lymphocytes of 900/mm3. C-reactive protein level was of 365 mg/L, procalcitonin was 3.4 ng/mL, ferritin was 1282 µg/L (normal <30), and lactate 2.4 mmol/L (normal <1.6). Renal and liver function tests were within normal range, and his troponin level was 550 ng/L (normal <34). Cutaneous biopsy showed a slightly inflammatory infiltrate in upper dermis, and direct cutaneous immunofluorescence was negative. Reverse transcription–polymerase chain reaction (RT-PCR) testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 [COVID-19]) was negative on nasopharyngeal swab, saliva, stool specimen, and skin biopsy. Extensive infectious inquiry and search for antinuclear antibodies were negative. Electrocardiogram showed diffuse negative T waves, and echocardiography displayed hyperkinetic left ventricle with normal ejection fraction, normal right cavities, and dilated noncompressible inferior vena cava. Thoracoabdominal computed tomography (CT) scan did not demonstrate pulmonary embolism or lung infection but did show signs of congestive heart failure with bilateral pleural effusion and wall thickening of the right colon with normal rectosigmoidoscopy. Treatment with volume resuscitation, noradrenaline, and antibiotics (ie, ceftriaxone and amikacin) was started and then high-flow nasal oxygenation was added because of respiratory function deterioration. Progressive clinical and biological features normalized, and the patient left the intensive care unit at day 8, while COVID-19 serology returned highly positive with immunoglobulin G (IgG) using enzyme-linked immunosorbent assay (ELISA) SARS-CoV-2 IgG Euroimmun. At 4 weeks’ follow-up he was healthy, and his heart CT scan and cardiac magnetic resonance imaging were normal with no sign of myocarditis or coronary aneurysms.
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-Parna Moghadam, MD, Laurent Blum, MD, Btissem Ahouach, MD, Aguila Radjou, MD, Céleste Lambert, MD, Agnès Scanvic, MD, Pascale Martres, MD, Véronique Decalf, MD, Edouard Bégon, MD, Claude Bachmeyer, MD
