The incubation period for COVID-19 is generally within 14 days following exposure, with  most cases occurring approximately four to five days after exposure. In a study of 1099 patients with confirmed symptomatic COVID-19, the median  incubation period was four days (interquartile range two to seven days). Using data from  181 confirmed cases in China with identifiable exposure, one modeling study estimated  that symptoms would develop in 2.5 percent of infected individuals within 2.2 days and  in 97.5 percent of infected individuals within 11.5 days. The median incubation period in  this study was 5.1 days. However, determinations of the incubation period can be imprecise and may differ by  the method of assessing exposure and the specific calculations used for the estimate.  Another study estimated incubation period using data from 1084 patients who had  traveled or resided in Wuhan and were subsequently diagnosed with COVID-19 after  leaving Wuhan. This study suggested a longer median incubation period of 7.8 days, with 5 to 10 percent of individuals developing symptoms 14 days or more after  exposure.  Among patients with symptomatic COVID-19, cough, myalgias, and headache are the  most commonly reported symptoms. Other features, including diarrhea, sore throat, and smell or taste abnormalities, are also well described. Pneumonia is the most frequent  serious manifestation of infection, characterized primarily by fever, cough, dyspnea, and  bilateral infiltrates on chest imaging. Although some clinical features (in particular smell  or taste disorders) are more common with COVID-19 than with other viral respiratory infections, there are no specific symptoms or signs that can reliably distinguish COVID 19. However, development of dyspnea approximately one week after the onset of initial  symptoms may be suggestive of COVID-19.

The range of associated symptoms was illustrated in a report of over 370,000 confirmed  COVID-19 cases with known symptom status reported to the CDC in the United States:

●Cough in 50 percent 

●Fever (subjective or >100.4°F/38°C) in 43 percent 

●Myalgia in 36 percent 

●Headache in 34 percent 

●Dyspnea in 29 percent 

●Sore throat in 20 percent 

●Diarrhea in 19 percent 

●Nausea/vomiting in 12 percent 

●Loss of smell or taste, abdominal pain, and rhinorrhea in fewer than 10 percent  each

On 7th February 2021, a forty two year-old previously healthy lady, non-smoker,  presented to our hospital for desaturation, fever and altered general status. Her past  surgical history includes only C-section. Upon presentation, pulmonary auscultation  revealed left basal crackles. Otherwise no significant findings. In emergency department, pan cultures were taken and blood was drowned for usual  lab tests and covid-19 panel, which showed lymphopenia (3%) and an acute  inflammatory process (CRP 186.7, procalcitonin level 19) with elevated D-Dimer (18.4),  ferritin (661) fibrinogen (7.72) and LDH (935) levels in favor of covid-19 infection. Surprisingly, she was found to have acute kidney injury with creatinine level of 20.4,  severe hypocalcemia (ca level 5) and hyperphosphatemia (11). On ABG’s she had  severe metabolic acidosis (PH 7.1, bicarb 6.4) with respiratory compensation (CO2  17.2). Further investigations included PCR covid-19 which turned to be positive, and CT  chest without contrast that revealed bilateral upper, middle and lower lobes ground  glass opacities affecting around 50% of lung parenchyma, findings typical of covid-19,  with left lower lobe consolidation (fig.1).

Patient was admitted to ICU for close monitoring and was put on nasal cannula 2-3  L/min. SPo2 did not drop less than 98%. She was started on antibiotherapy including  Ceftriaxone and macrolides for super bacterial infection, on therapeutic anticoagulation  for hypercoagulable state, and steroids, given her high oxygen requirements. In  addition, Kimal was inserted in order to start hemodialysis. On the second day, patient developed one episode of tonic-clonic seizure for which she  was started on benzodiazepine (depakine). No further investigations were done since it  was her first episode that could be related to uremic encephalopathy.

Repeated labs on the upcoming days were significant for further increase in ferritin and  D-dimer that reached 1770 and 20 respectively. However, creatinine, BUN and  phosphorus were decreasing progressively after dialysis sessions to reach a level of  6.5, 61.8 and 6.2 respectively. Unfortunately, patient continued to deteriorate clinically;  she was not cooperative at all and hemodynamically unstable that she was put on  norepinephrine.

On day 6 of admission, her physical exam revealed hemiplegia mainly at the left upper  limb. For that reason, an MRI and an EEG were ordered in addition to metabolic  workup: ammonia level, TSH, vit B12, folic acid. Hyperintense lesions in the right  parietal lobe were found on MRI in favor of ischemic CVA (fig. 2,3). Moreover, EEG  showed focal subclinical epileptic seizures. Therefore, other antiepileptics (epanutin and  Keppra) were added. In contrast, all metabolic work up was normal.

On a side note, patient was always complaining of persistent shoulder and back pain so  the differential of multiple myeloma was made regarding her high creatinine level, but  serum protein electrophoresis was negative for M protein, and shoulder x-ray didn’t  show any lytic lesions however she was found to have left displaced shoulder fracture  that was treated conservatively. 

On twenty second of February_ day 16 of admission_ patient started to ameliorate  clinically, oxygen delivery was tapered and PO intake was initiated. Inflammatory  markers became negative and lymphopenia has resolved (23%). Consequently, she  was transferred to regular floor and was discharged later home with AV fistula for  chronic hemodialysis. She had shoulder joint replacement surgery later on.

CVA and renal failure may be a possible initial presentation of COVID-19. Clinicians and  health care providers should consider the presence of COVID-19 with bizarre  manifestation during this COVID-19 pandemic.

Figure 1: Chest CT

Figure 2: Brain MRI Axial View 

Figure 3: Brain MRI Sagittal View

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