We present a case history of a patient with severe dementia and COVID-19 who had a prolonged and fluctuating course of illness. The PCR tests for SARS-CoV-2 alternated between positive and negative results, which complicated the diagnosis and choice of isolation regime.
A man in his sixties with severe Alzheimer-type dementia developed symptoms in the upper respiratory tract with a runny nose and a slight cough. Some months previously, he had been admitted from a nursing home to the psychogeriatric department because of psychomotor agitation. He had no previous history of cardiac or pulmonary disease. The day after symptom onset, he was asymptomatic. Thus, he was not tested for SARS-CoV-2, since his condition was believed to be a common cold. Because of recurring symptoms and a new onset of fever ten days later, the patient was isolated and tested for SARS-CoV-2. Two days later, the result came back positive.
In the weeks that followed, the patient was bedridden. After two weeks he was considered pre-terminal because of dyspnoea and considerable general frailty. Mechanical ventilation was discussed, but assessed as not relevant after a consultation with the somatic hospital.
The further course of disease was of fluctuating nature. The dominant respiratory symptoms included a runny nose, cough and dysphagia. He also had a recurrent fever, especially in the afternoon and evening. After some weeks he also developed atypical symptoms, such as noticeably pale hands, rust-coloured urine, swollen feet and orange-coloured blotches on the upper and lower extremities and nails. In terms of behaviour, during better periods he was wandering and agitated. Maintaining infection control procedures was at times challenging. Even many weeks into the course of disease, his best days were not as good as before symptom onset. The clinical picture, characterised by fluctuations in activity and cognition, was fully consistent with delirium.
An oropharyngeal/nasopharyngeal sample for SARS-CoV-2 was analysed with a polymerase chain reaction test (PCR) on several occasions during the course of disease (on days 10, 40, 49, 62, 68 and 78, respectively). Proper collection of the sample was occasionally challenging. The first and the penultimate tests were positive, the others came back negative. The first positive test had a low cycle threshold (Ct) value (19), while the second and final positive tests had a high Ct value (38). C-reactive protein (CRP) was slightly elevated throughout the course of disease, with the highest value (83 mg/l) after two weeks of illness. A differential count of white blood cells showed normal findings or only a slightly elevated level with no obvious relation to disease intensity. There was no suspicion of a bacterial superinfection.
With the exception of the days when he was considered to be at a pre-terminal stage, his nutritional intake was generally good. More than two months after symptom onset he had his last day with fever. The remaining symptoms also subsequently receded. For the next seven days the patient had no clinical signs of respiratory symptoms, and the last test for SARS-CoV-2 taken in this period was negative. The isolation of the patient could thus finally be lifted.
The patient's next of kin have consented to the publication of this article. The use of clinical information has been approved by the data protection officer at Innlandet Hospital Trust (case number 137313). The article has been peer reviewed.