LAUSR

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: As the COVID-19 pandemic progresses, genetic variants have been identified globally, including the UK, South Africa, and Brazil strains. These variants exhibit genetic mutations in spike proteins and open reading frame regions. Rising cases of COVID-19 strains call to question the accuracy of current polymerase chain reaction (PCR) testing in detecting genetic variants. CASE PRESENTATION: A 76-year-old male nursing home resident was brought to the emergency department (ED) by ambulance due to progressively worsening dyspnea. His past medical history was remarkable for COPD and diabetes mellitus type II. On initial presentation, his respiratory rate was 30 breaths per minute, heart rate was 128 beats per minute, blood pressure was 135/64 mmHg, and oxygen saturation was 92% on supplemental oxygen via bilevel positive airway pressure (BIPAP). Physical exam was remarkable for bilateral rhonchi with accessory muscle use. Labs were remarkable for a white blood cell count of 16.5 109/L with lymphopenia, lactic acid of 2.2 mmol/L, and a d-dimer of 5250 ng/mL. Chest CT showed bilateral patchy ground glass infiltrates, fibrotic changes, and small bilateral pleural effusions (Image 1). He tested negative for influenza A and B, Mycoplasma pneumoniae, Streptococcus pneumonia, and Legionella. Sputum cultures showed no growth. The patient tested negative for COVID-19 twice by RT-PCR analysis (Abbott Laboratory, Chicago, IL). He was treated with intravenous steroids and broad-spectrum antibiotics. He was unable to be weaned from BIPAP to a lower level of supplemental oxygen. Eight days after hospital admission, the patient tested positive for COVID-19 IgM and IgG antibodies. After 12 days of treatment, the patient suffered a fatal cardiac arrest. DISCUSSION: We present an elderly man with a clinical symptoms and imaging findings highly suggestive of COVID-19, despite multiple negative RT-PCR tests. The patient did not improve despite treatment with broad spectrum antibiotic and intravenous corticosteroids. Patients had positive COVID-19 IgM antibodies, despite no known recent prior infection. Although the lab utilized for COVID-19 RT-PCR analysis asserts that testing is not impacted by genetic variants, these cases challenge the true sensitivity of this testing in detecting emerging strains. CONCLUSIONS: There are potentially many patients in the community hospitals presenting with COVID-19 variants that are not detected by existing RT-PCR testing. The genetic diversity of COVID-19 may diminish the sensitivity of RT-PCR testing, as labs across the country utilize different primers and probes with variable sensitivities in detecting variants. Clinicians should maintain a high suspicion for COVID-19, despite negative PCR testing. REFERENCE #1: Wang R, Hozumi Y, Yin C, Wei G-W. Mutations on COVID-19 diagnostic targets. Genomics. 2020;112(6):5204-5213. REFERENCE #2: Sapoval N, Mahmoud M, Jochum MD, et al. SARS-CoV-2 genomic diversity and the implications for qRT-PCR diagnostics and transmission. Genome Res. 2021;31(4):635-644. DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response No relevant relationships by Jessica Baek, source=Web Response No relevant relationships by Renuka Reddy, source=Web Response No relevant relationships by Claudia Tejera Quesada, source=Web Response no disclosure on file for Adam Wellikoff;