An 80-year-old man presented with respiratory distress and was found to have dual pneumonia from Streptococcus pneumoniae and COVID-19. He required non-invasive ventilation but deteriorated with septic shock. Aggressive treatment including antibiotics, steroids, and supportive care resulted in clinical stability by day 5. However, he developed oral candidiasis. After a prolonged hospital stay with de-escalation of treatments, the patient was discharged on day 11 in a stable condition. Dual pneumonia can be fatal, so pneumococcal vaccination is important for high-risk groups. A high index of suspicion and timely treatment of bacterial infections like S. pneumoniae is critical for patients with viral pneumonia.

1. DUAL PNEUMONIA
(PNEUMOCOCCAL + COVID-19)
– CASE PRESENTATION
DR. VITRAG H SHAH
MD Medicine, FNB Critical Care, EDIC-UK (European Diploma in Critical Care)
PHYSICIAN & CHIEF INTENSIVIST
VELOCITY HOSPITAL
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2. CASE
• 80 year old male, K/C/O HTN, PREDIABETES
• Recent h/o surgery for Inguinal Hernia
• Presented with breathlessness at rest and hypoxia
(70% spo2 on room air) on 14/1/22, 10pm
• C/O breathing difficulty, decreased oral intake, cough
with expectoration and vomiting for 3-4 days, consulted
to nearby hospital , COVID-19 Rapid test done which
was positive.
• HRCT Thorax done s/o B/L GGO, B/L (Lt>Rt) L/L focal
consolidation s/o COVID-19 pneumonia - CTSS 9/25
25% lung involvement.

3. HRCT – 14/1/22
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4. • Vitals on arrival: GCS 14/15, RR 32/min, BP 80/50
mmhg, HR 68/min, SpO2 94% on O2@10 lit/min with
NRBM
• Routine blood reports, ABG, PCT, CRP, D-DIMER,
NTPROBNP, HBA1C, BLOOD C/S, COVID-19 IgM
Antibody sent. Sputum C/S advised but couldn’t send
as difficulty in expectoration.
• RBS by Glucometer - 214
• ECG – SINUS RHYTHM, T INVERSION V4-V6.
• POCUS – ECHO SCREEN – EF – MODERATE,
GENERELIZED HYPOKINESIA, IVC 1.8 CM , >50%
COLLAPSIBLE (?D/T RESPIRATORY DISTRESS).
LUNG USG SCREEN – B/L >3 B-LINES, AIR
BRONCHOGRAM RIGHT I/M
CASE

5. CASE – WHAT WILL YOU DO NEXT?
Initial resuscitation (first 30-60min)
• One EJV & One peripheral cannula inserted
• NS 500cc IV bolus given
• NA infusion started
• NIV (PC-BIPAP) started with 100% FiO2, 7 PEEP, 14 PS, 16 Pi, RR 24
& Intubation sos planned
• Inj Hydrocortisone 100mg iv stat given
• Inj Meropenam 2gm loading dose given
• Inj Remdesivir 200mg loading dose given
• Foley’s catheterization done
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6. CASE – INITIAL LAB (FIRST 30-60MIN)
• ABG – Ph 7.2, PCO2 43.4, PO2 59.7, HCO3 16.4, Lactate 4.5
• Hb 15.1 TLC 15400 PLT 170000
• CRP 110.2 PCT 50.6
• Creat 2.17 Na 135 K 5.55
• Albumin 2.09, Rest LFT - WNL
• D-dimer 1050 NTProBNP 7964.1
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7. FURTHER COURSE
• Pneumococcal urinary antigen sent i/v/o focal consolidation and
multiorgan involvement which is unlikely due to isolated COVID-19
pneumonia – it turned out to be positive.
• Full 2D ECHO by cardiologist done – EF 30%, RWMA present,
Moderate PHT,IVC 2cm >50% collapsing.
• COVID-19 IgM Antibody report – positive – 3.65
• Patient did not tolerate NIV, intermittent NIV-NRBM with 10-15 lit
Oxygen continued.
• Vitals in Next 12 hours : HR 84/min, RR 26-30/min, SpO2 94% with NIV
100% FiO2, BP 100/60 with Norad infusion
• Next day (15/1/22), respiratory distress decreased. Taken on HFNC
instead PC-BIPAP & semiprone positioning done.
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8. What will you do next? (1-12 hours)
• Inj MOXIFLOX 400MG IV OD started for dual pneumococcal cover
• Inj Remdesivir and Meropenam continued.
• Inj Hydrocortisone 100mg IV 1-1-1 continued
• Inj Ascorbid Acid 1.5gm IV 1-1-1 started
• Inj Heparin 5000unit IV 1-1-1-1 started
• IV Fluid decreased & plan to stop as per POCUS and I/P , U/O in next 24
hours
• Inj Dytor 20mg iv stat given & advised SOS subsequent dose
• Aspirin & Atorvastatin started.
• NA continued targeting MAP >65mmhg
• RT insertion done and RT feed started
• HFNC continued.
• Semiprone left/right positioning done and tolerated.
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9. FURTHER COURSE – Day 2-3
• Patient was maintaining SpO2 >94-95% on HFNC (FiO2 98-90% Flow
40-50).
• Labs on 16/1/21:
◦ Hb 16.7, TLC 19080, PLT 165000
◦ CRP 605.4 PCT >100
◦ Creat 2.1 Na 141 K+ 5.7
• On 16/1/22 evening, patient had Atrial Fibrilation with high ventricular
Rate , BP 90/60 with Norad infusion. Inj Amiodarone 150mg bolus f/b
infusion started and Inj Digoxin 0.25 loading dose given, Inj MGSO4
2gm IV given , still Afib persisted, so single DC Shock of 100J given and
sinus rhythm reverted.
• Blood sugar level went high, insulin infusion started.
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10. CASE – WHAT WILL YOU DO NEXT?
• Trop-I (High – 135.2 ng/L) , TSH (0.8), Magnesium level (3.4) sent.
• Shock, High CRP & PCT, ARDS indicating ?worsening sepsis-MODS due to
pneumococcal pneumonia / ??cytokine strom due to COVID-19 .
• Considering age and high sugar , so high risk of secondary infections,
Tocilizumab / other immunomodulator weren’t started.
• Inj ULINASTATIN 2vial BD and Inj Sepsivac 0.3 ml iv in 50cc NS OD for 3
days started i/v/o septic shock and ARDS . (No strong data, but no harm
and possible benefit)
• UFH stopped and LMWH started.
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11. FURTHER COURSE – DAY 3-5
• Clinically patient became stable, NA requirement decreased,
Maintaining on HFNC with FiO2 requirement derecased upto 60-70% by
4th Day.
• CRP decreased on 17/1/22 85.8, again increased on 18/1/22 266.3.
• Repeat HRCT thorax done on 18/1/22 s/o increase in GGO, & 25%
lung involvement, no cavity/other infective focus..
• Creatinine decreased to 2.1 and CRP decreased to 89.3 ON 19/1/22.
• Patient was taken on Nasal cannula with O2 @2-4 litre/min on 19/1/22.
• Mobilization started. Over next 2-3 days intermittent off oxygen trial
given and chest physiotherapy and spirometry started.
• Repeat COVID-19 RTPCR done which was negative, so patient was
shifted to Non-COVID-19 ward in stable condition on 20/1/22.
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12. Repeat HRCT – 18-1-22
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13. FURTHER COURSE – DAY 5-10
• Patient remains stable, maintaining SpO2 > 92-94% without oxygen
from 22/1/22.
• WBC count (11000) and CRP (35) decreased on 21/1/22.
• C/O difficulty in swallowing, oral ulcers and candidiasis present.
• Candid mounth paint , Fluconazole and other symptomatic treatment
started.
• Antibiotic deescalation done. Tab Apixaban started and LMWH stopped.
• Nutrition increased gradually and patient started walking without
support.
• Patient discharged on day 11 in absolutely stable condition.
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14. Take Home Message
• Pneumococcal pneumonia is fatal and presented with MODS in elderly
& immunocompromized patients.
• Prior vaccination of all high risk patients and elderly as per
recommendation can prevent such fatal disease and save patient and
subsequent cost of hospitalization as well.
• Keep high index of suspicion of pneumococcal pneumonia in patient
presenting with any CAP , it can be associated with viral
(Influenza/COVID-19) as well which can be more fatal if not diagnosed,
• Pneumococcal urinary antigen has low sensitivity but high specificity
and immediate diagnosis can be done, so send in CAP patients along
with blood c/s and sputum c/s.
• Choose immunomodulater wisely, deescalate antibiotic after c/s and
stabilization , control blood sugar level below 180 , chosing IV steroid as
per patient condition – indicated in both severe COVID-19 and
pneumococcal disease (hydrocortisone preferred over longer acting
steroid in case of shock).
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15. Questions?
Contact :
dr.vitrag@gmail.com
9712909924

16. www.drvitragshah.com
Dr. Vitrag Shah
Email: dr.vitrag@gmail.com
Mo. 9712909924
THANK
YOU