Case of the Month 

August 2020

Yolanda Van Zyl – Clinical Coordinator Infection Control, Paarl Hospital
Reviewed by: Lesley Devenish -Infection Prevention and Control Project Co-ordinator,
Department of Clinical Microbiology and Infectious Diseases NHLS

Case Presentation
37-year-old male patient presented on 20/07/2020 at the emergency centre with a 7- day history of anosmia, cough, dyspnoea, diarrhoea, vomiting and myalgia. Patient known to have had a positive COVID-19 contact at work. Patient’s wife is pregnant with their first-born child. He was already in quarantine to protect her.

Co-morbidities: Central obesity, Diabetes mellitus type 2 (on metformin only) and hypertension

Observations on admission: Blood pressure = 115/73 mmHg, respiratory rate = 21/min, pulse rate = 112 /min, temperature = 35.5°C, saturation on room air = 94%, HGT = 7.9mmol/L, haemoglobin=16.2g/dl


  • WCC = 7.36 (3.92-10.40)
  • CRP = 48 (<10)
  • Creatinine = 164 (64-104)
  • Urea = 7.5 (2.1-7.1)
  • SARS-CoV-2 PCR: Positive
  • Creatinine = 124 (64-104)
  • Creatinine = 110 (64-104)
  • D-Dimer Quantitative = 0.47 (0.00-0.25)
  • Creatinine = 114 (64-104)
  • Creatinine = 107 (64-104)

Question 1: What is the difference between isolation and quarantine?

Answer to Question 1

Isolation is a when a sick individual with a confirmed contagious disease (e.g. COVID19) is separated from others without that disease. Quarantine is when a person who does not have symptoms for a contagious disease (e.g. COVID-19) has been in close contact with someone who has it and is separated from others who are not exposed; or who is awaiting test results.

Differential diagnosis:
  • Typical Community acquired Pneumonia (CAP) – discounted due to bilateral positive lung finding
  • Atypical pneumonia – discounted due to bilateral positive lung finding
  • Tuberculosis- chest x-rays not suggestive, no purulent sputum
  • Other viral diseases – discounted because of known high risk positive COVID-19 contact.
Management: Patient admitted to a general ward, nursed in contact and droplet precautions. He was started on nasal prong oxygen and responded well. Healthcare workers in the ward wore surgical masks, visors, plastic aprons and non-sterile gloves to protect themselves against droplet and contact transmission. On day 3 in the ward, he suddenly deteriorated and was recorded as having an oxygen saturation reading of 83% on double barrel oxygen. He was noticeably distressed and tachycardic. He was discussed with a consultant and was accepted to high care for high flow nasal oxygen. He spent a total of 13 days in high care (10 days on high flow and 3 days on 40% FMO2). He completed a 14-day course of prednisone at 40mg daily and received therapeutic clexane.

Healthcare workers in high care wore N95 respirators, visors, disposable gowns and nonsterile gloves as standard precautions (to protect themselves against droplet and contact transmission). They used additional precautions to protect against airborne contagions due to aerosol-generating procedures (AGP) (e.g. high flow nasal oxygen). They practiced strict hand hygiene according to the WHO “My 5 Moments” and also cleaned and disinfected the environment frequently with soap and water followed by a hypochlorite solution 1000ppm or 70% alcohol surface disinfectant

Patient developed a thrombophlebitis in his right arm while in HCU and was started on Flucloxacillin. He was transferred back to the general ward and successfully weaned to room air. He remained comfortable on room air with a saturation of 92%. Patient also developed an acute kidney injury that resolved with supportive management.

Patient was discharged on the 13th August 2020 after 24 days in hospital. He was in time for the birth of his first born.

Question 2: Provide a list of aerosol-generating procedures.

Answer to Question 2

  • Intubation, extubation and related procedures such as manual ventilation and open suctioning
  • Tracheotomy/tracheostomy procedures (insertion/open suctioning/removal)
  • Bronchoscopy
  • Surgery and post-mortem procedures involving high-speed devices
  • Some dental procedures (such as high-speed drilling)
  • Non-Invasive Ventilation (NIV) such as Bi-level Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure ventilation (CPAP)
  • High-Frequency Oscillating Ventilation (HFOV)
  • High Flow Nasal Oxygen (HFNO), also called High Flow Nasal Cannula
  • Induction of sputum for laboratory test
In addition, the following are also considered AGP
  • Collecting nasopharyngeal and oropharyngeal swabs;
  • Chest physiotherapy;
  • Reprocessing ventilator circuits and respiratory equipment;
  • Cardiopulmonary resuscitation, including bag-mask ventilation;

Question 3: Name the infection prevention and control measures in intensive care for COVID-19.

Answer to Question 3

Intensive Care

  • Bed spacing- 3m or more to allow physical distancing between patients and ease of movement of staff and equipment
  • Good ventilation- 160L/sec/patient or 12 air changes per hour (ACH)
  • Closed suctioning with the use of fresh sterile water each time to clean the suction catheter. (Open suctioning is not recommended)
  • Dedicated ventilator equipment with single patient use circuit
  • Bacterial/viral filter on expiratory limb of ventilator equipment
  • Dedicated patient care equipment
  • Perform hand hygiene and change gloves after each patient contact
  • Do not touch face, front of apron, mask, goggles or face shield at any time
  • Keep patient charts outside the cubicle/room, if possible
  • Always carry out hand hygiene before and after touching the notes (persistence on cardboard and paper has been reported)
Final diagnosis:

COVID-19 pneumonitis

The World Health Organization (WHO) declared Covid-19 a global pandemic on 11th March 2020. The first case was diagnosed in South Africa on 5th March 2020. South Africa faces a particular challenge given the large vulnerable immunocompromised population living in overcrowded conditions.

Question 4: Name the characteristics of the SARS CoV-2 virus.

Answer to Question 4

SARS-CoV-2 is a novel coronavirus, having likely thought to originate from wild pangolins and bats from ongoing research. It has recently been discovered to cause disease in humans. Person to person transmission has been rapid, causing large community outbreaks across the globe. The virus infects and colonises the human nasopharynx and upper respiratory tract, later affecting the lower respiratory tract leading to pneumonia and respiratory failure which can result in death (variable case fatality rates reported 1-5%). It is an enveloped virus which makes it fragile and vulnerable to heat, chemicals and ultraviolet sunlight.

  1. COVID-19 Disease: Infection Prevention and Control Guidelines Version 2 (21stMay 2020)
  2. Coronavirus disease 2019 (COVID-19) caused by a Novel Coronavirus (SARSCoV-2) Guidelines for case-finding, diagnosis, and public health response in South Africa Version 3, June 2020
  3. Conly et al. Antimicrobial Resistance and Infection Control (2020) 9:126 https://doi.org/10.1186/s13756-020-00779-6
Internal Medicine Department – Paarl Hospital

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