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1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">High-flow oxygen therapy is started at 12 lmp and a Fi02 of 35&#37;&#46; The patient remains with persistent fever&#44; tachypnea&#44; subcostal retraction&#44; and his admission to the pediatric ICU is authorized&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Initially&#44; high-flow oxygen therapy is maintained while increasing parameters with good tolerance&#46; However&#44; the patient shows work of breathing with universal retraction and desaturation&#44; and it is decided to proceed with orotracheal intubation and connection to invasive mechanical ventilation&#46; A new PCR test to discard the presence of SARS-CoV-2 in bronchial aspirate is run again but it tests negative once again&#46; Lopinavir&#47;ritonavir&#44; azithromycin&#44; and cefepime are all withdrawn and meropenem &#40;60<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; is administered&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The respiratory pathogens panel test &#40;IgM and IgG antibodies against <span class="elsevierStyleItalic">Legionella pneumophila</span>&#44; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#44; and <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>&#41;&#44; the galactomannan antigen blood test&#44; and the viral load of cytomegalovirus all tested negative&#59; no further serology tests of such control panel were run&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The thoracic x-ray performed the next day confirmed the complete opacification of the right lung with left paracardiac infiltration &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The blood test performed at the ICU admission confirmed the following parameters&#58; C-reactive protein &#40;CRP&#41;&#44; 11&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; procalcitonin &#40;PCT&#41;&#44; 2&#46;63<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; triglycerides&#44; 250<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; lactate dehydrogenase&#44; 780 U&#47;L&#59; ferritin&#44; 1734<span class="elsevierStyleHsp" style=""></span>&#956;L&#47;L&#59; interleukin 6&#44; 105<span class="elsevierStyleHsp" style=""></span>pg&#47;dL&#59; lymphopenia&#44; 750&#47;&#956;L&#59; platelets&#44; 70 000&#47;&#956;L&#44; and D-dimer 2&#46;72<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL&#46; The CRP&#44; PCT&#44; triglyceride&#44; and lactate dehydrogenase levels dropped gradually&#44; ferritin levels went up to 2016<span class="elsevierStyleHsp" style=""></span>&#956;L&#47;L on day 2&#44; and IL-6 levels reached 141<span class="elsevierStyleHsp" style=""></span>pg&#47;dL on day 3 without further determinations&#46; Lymphopenia and thrombocytopenia recovered on day 4 while D-dimer levels remained stable&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Due to these findings&#44; the epidemiological situation&#44; the situation of progressive respiratory failure&#44; and the radiological images obtained&#44; the case was discussed with the Unit of Infectious Diseases&#46; It was decided to administer tocilizumab 8<span class="elsevierStyleHsp" style=""></span>mg&#47;kg in a single dose and run a total antibody test looking for the presence of IgM&#44; IgG&#44; and IgA antibodies against SARS-CoV-2 &#40;two-step chemiluminescent immunoassay&#44; Elecsys anti-SARS-CoV-2&#44; Roche&#41;&#44; and a new PCR in plasma &#40;500<span class="elsevierStyleHsp" style=""></span>mL of plasma mixed with the same amount of lysis solution&#41; and in feces &#40;fecal suspension in 500<span class="elsevierStyleHsp" style=""></span>mL of physiological serum using the same procedure as in plasma processed using the Cobas 6800 system &#40;Roche&#41;&#46; Everything tested negative&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The next day&#44; the PCR test to discard <span class="elsevierStyleItalic">Pneumocystis jirovecii</span> in bronchial aspirate tested positive and cotrimoxazole was titrated to therapeutic doses&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The patient&#8217;s respiratory condition started to improve&#44; and he was extubated on day 8&#46; The patient was discharged from the ICU and transferred to the hospital pediatric oncology unit&#46; He showed eupneic breathing upon return to room air with oral tolerance to monotherapy with cotrimoxazole&#46; The patient received no corticoids during his ICU stay&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A month later&#44; the antibody test against the new coronavirus was run again but it tested negative one more time&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In light of the 2 diagnostic possibilities of our case&#44; we were facing an epidemiological context with great exposure to SARS-CoV-2&#44; compatible radiological and analytical findings&#44; but negative test samples without ever running a PCR test in bronchoalveolar lavage &#40;that performs better&#41; or a rectal swab&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We should not forget that inflammatory parameters are not specific of this infection&#46; However&#44; high levels of IL-6 and PCR are actually considered independent risk factors for its severity&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> High procalcitonin levels are suggestive of bacterial over-infection&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this case its discrete elevation was considered an acute-phase reactant&#46; <span class="elsevierStyleItalic">Pneumocystis</span> is an environmental fungus that can cause false positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; its diagnosis could not be excluded since we saw refractory infiltrates in the patient that did not respond to therapy within the first 24&#8722;72<span class="elsevierStyleHsp" style=""></span>h&#46; Still&#44; the response to therapy was faster than expected&#46;</p></span>"
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Scientific Letter
SARS-CoV-2 or Pneumocystis jirovecii? A case report
¿SARS-CoV-2 o Pneumocystis jirovecii? A propósito de un caso
A.B. González Moyanoa,
Corresponding author
anabelengmoyano@gmail.com

Corresponding author.
, L. Medina Ramosa, M. del Cañizo Moreirab, E. Merino de Lucasc, M. González Lorenzoa, M. Esteban García-Fontechaa
a Medicina Intensiva, Hospital General Universitario de Alicante, Alicante, Spain
b Oncología Infantil, Hospital General Universitario de Alicante, Alicante, Spain
c Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, Alicante, Spain
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is administered&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The respiratory pathogens panel test &#40;IgM and IgG antibodies against <span class="elsevierStyleItalic">Legionella pneumophila</span>&#44; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#44; and <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>&#41;&#44; the galactomannan antigen blood test&#44; and the viral load of cytomegalovirus all tested negative&#59; no further serology tests of such control panel were run&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The thoracic x-ray performed the next day confirmed the complete opacification of the right lung with left paracardiac infiltration &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The blood test performed at the ICU admission confirmed the following parameters&#58; C-reactive protein &#40;CRP&#41;&#44; 11&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; procalcitonin &#40;PCT&#41;&#44; 2&#46;63<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; triglycerides&#44; 250<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; lactate dehydrogenase&#44; 780 U&#47;L&#59; ferritin&#44; 1734<span class="elsevierStyleHsp" style=""></span>&#956;L&#47;L&#59; interleukin 6&#44; 105<span class="elsevierStyleHsp" style=""></span>pg&#47;dL&#59; lymphopenia&#44; 750&#47;&#956;L&#59; platelets&#44; 70 000&#47;&#956;L&#44; and D-dimer 2&#46;72<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL&#46; The CRP&#44; PCT&#44; triglyceride&#44; and lactate dehydrogenase levels dropped gradually&#44; ferritin levels went up to 2016<span class="elsevierStyleHsp" style=""></span>&#956;L&#47;L on day 2&#44; and IL-6 levels reached 141<span class="elsevierStyleHsp" style=""></span>pg&#47;dL on day 3 without further determinations&#46; Lymphopenia and thrombocytopenia recovered on day 4 while D-dimer levels remained stable&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Due to these findings&#44; the epidemiological situation&#44; the situation of progressive respiratory failure&#44; and the radiological images obtained&#44; the case was discussed with the Unit of Infectious Diseases&#46; It was decided to administer tocilizumab 8<span class="elsevierStyleHsp" style=""></span>mg&#47;kg in a single dose and run a total antibody test looking for the presence of IgM&#44; IgG&#44; and IgA antibodies against SARS-CoV-2 &#40;two-step chemiluminescent immunoassay&#44; Elecsys anti-SARS-CoV-2&#44; Roche&#41;&#44; and a new PCR in plasma &#40;500<span class="elsevierStyleHsp" style=""></span>mL of plasma mixed with the same amount of lysis solution&#41; and in feces &#40;fecal suspension in 500<span class="elsevierStyleHsp" style=""></span>mL of physiological serum using the same procedure as in plasma processed using the Cobas 6800 system &#40;Roche&#41;&#46; Everything tested negative&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The next day&#44; the PCR test to discard <span class="elsevierStyleItalic">Pneumocystis jirovecii</span> in bronchial aspirate tested positive and cotrimoxazole was titrated to therapeutic doses&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The patient&#8217;s respiratory condition started to improve&#44; and he was extubated on day 8&#46; The patient was discharged from the ICU and transferred to the hospital pediatric oncology unit&#46; He showed eupneic breathing upon return to room air with oral tolerance to monotherapy with cotrimoxazole&#46; The patient received no corticoids during his ICU stay&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A month later&#44; the antibody test against the new coronavirus was run again but it tested negative one more time&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In light of the 2 diagnostic possibilities of our case&#44; we were facing an epidemiological context with great exposure to SARS-CoV-2&#44; compatible radiological and analytical findings&#44; but negative test samples without ever running a PCR test in bronchoalveolar lavage &#40;that performs better&#41; or a rectal swab&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We should not forget that inflammatory parameters are not specific of this infection&#46; However&#44; high levels of IL-6 and PCR are actually considered independent risk factors for its severity&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> High procalcitonin levels are suggestive of bacterial over-infection&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this case its discrete elevation was considered an acute-phase reactant&#46; <span class="elsevierStyleItalic">Pneumocystis</span> is an environmental fungus that can cause false positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; its diagnosis could not be excluded since we saw refractory infiltrates in the patient that did not respond to therapy within the first 24&#8722;72<span class="elsevierStyleHsp" style=""></span>h&#46; Still&#44; the response to therapy was faster than expected&#46;</p></span>"
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