A Case of COVID-19 and Community-acquired Pneumonia in Alpha-1 Antitrypsin Deficiency

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Abstract Introduction: COVID-19 is a viral infectious disease that has taken the lives of millions of people around the world over the last five years. It has to be taken seriously in any clinical setting due to its effects on the respiratory system. Alpha 1 antitrypsin deficiency (AATD) is an inherited genetic disorder that impacts the lungs, liver, and skin. In AAT deficiency, unopposed neutrophil elastase activity in the lungs destroys pulmonary parenchyma, eventually causing panacinar emphysema. We present a patient with a past medical history of Alpha 1 antitrypsin deficiency with emphysema and cirrhosis who was diagnosed with COVID-19 requiring ICU level of care. Case presentation: A 47-year-old female patient with a past medical history of Alpha 1-antitrypsin deficiency on prolastin, emphysema, cirrhosis, and Chronic hypoxic and hypercapnic respiratory failure on 6L NC 24/7 who presented to the ED with fevers, chills, worsening mental status, dyspnea, and productive cough for the past two days. Upon arrival at the ED, the patient's vitals were significant for tachycardia, tachypnea, and hypoxia. Workup revealed positive Covid 19 infection. Labs showed WBC 2.2, Hgb 10.6, Plt 23, and mildly elevated AST and AlK phosphate. Ammonia 62, Procalc 0.21. VBG showed pH 7.22, pCO2 80, and HCO3 33. She was placed on BiPAP and treated with steroids for COPD/COVID before being transferred to ICU. CT Chest showed left lower lobe pneumonia with trace pleural effusion and severe emphysema. The patient was treated with Levaquin for pneumonia, HFNC, and BiPAP as needed, in addition to bronchodilators. The patient was not a candidate for antivirals or immunotherapy due to her cirrhosis. The patient was started on Lactulose for hyperammonemia and altered mental status. Fortunately, the patient recovered over a few days and was discharged on oral antibiotics and steroids. She is on home Prolastin and on the list for lung and liver transplants. Conclusion: We describe COVID-19 and community-acquired pneumonia in a patient with AATD with severe emphysema and cirrhosis. Aggressive treatment of this patient's comorbidities led to her recovery, but many may not be as fortunate as in AATD; COVID-19 usually presents with severe symptoms and complications. Early identification and treatment are key to reducing rural and community hospital mortality.

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