COVID-19: An Actual, Real Case

April 9, 2020

Before I begin, let me say that my heart goes out to all those affected by this pandemic. By the time the coronavirus has run its current course through the earth, there will be very few left untouched by its impact in one way or another. People are suffering in so many ways, and there has rarely been a greater need for compassion, hope, stability, and trust. I don’t often pray global prayers, but the message that “we are all in this together” really rings true now more than it ever has. I pray to my Lord for each of you reading this… that you will find supernatural comfort and peace in a season where the natural human reaction is frustration and disappointment.

As most people know by now, the coronavirus that is causing the current pandemic can cause a broad spectrum of disease experience, ranging from minor symptoms (even unnoticeable) to severe Acute Respiratory Distress Syndrome (ARDS) and death. COVID-19 is more insidious than its recent predecessors, SARS and MERS. It is far more damaging than its other predecessors, HCoV-229E and HCoV-OC43, which could account for anywhere from 15-30% of common colds in decades past.

With all the extensive media coverage, sensationalism, opinion and misinformation out in the wide world, I felt compelled to write a blog that tells an accurate account of one of our patients who tested positive for COVID-19, with his permission and assistance to make his story as precise as possible to the facts of how he progressed through the days of illness. While this account does not reflect everyone’s experience, it is not too dissimilar from what many people will go through. This story offers a testimony of what a real case could be like. As a matter of medical truth, one cannot take the experience of a single person and reliably apply it to all patients. This one case serves anecdotally as an example of what COVID-19 did in fact look like for a real patient.

I received the initial call at 10:45 pm on Monday, March 16th. A little over a week earlier, he had traveled by plane to multiple places in the state of Texas on business. A mild dizziness began on March 13th, about a week after the travel (and likely exposure). Fever up to 102°F was also present, along with a mildly congested cough that was mostly dry. There was mild nasal congestion, mild sinus pressure, and a significant headache that was made worse by the dry cough. Low back pain was present too, greater on the left, but without widespread body aches.

By Sunday (March 15th), there had appeared a mild shortness of breath with the exertions of the normal day. The breathing difficulty wasn’t extreme or debilitating. Simple activities like going up a few stairs, lifting a medium-weight object and carrying it across a room, or just walking distances of greater than 50 feet would cause him to get winded, and that wasn’t normal for him, of course. The fever remitted on Sunday, but it then relapsed on Monday and was close to 101°F. Homeopathic remedies had not been noticeably helpful thus far.

He is an average male in his 30’s without any significant chronic medical history. He’s what you might call a “normal guy.” He had been home with his wife now for over a week after travelling, and the COVID-19 pandemic was being plastered throughout every media channel. “15 Days to Slow The Spread” started on March 16th, and he was concerned that he or his wife could have the coronavirus. What if one of them had a bad outcome?

So, we talked. There weren’t other symptoms to suggest other disease. Fatigue was mildly part of it, but the marked malaise that often comes on strong with the flu was not present. Abdominal symptoms were absent, and there was no rash. In fact, if it wouldn’t have been for the relapse of the fever on Monday and shortness of breath with exertion, he might not have called me.

Because of the risk of COVID-19 together with the mild nature of the symptoms, we chose strict social distancing, supportive care, and observation as a treatment strategy. The “supportive care” aspect could take many forms, but we individualized it to fit what his needs and preferences were. For him, that meant a natural approach, beginning with a strong spiritual support marked by Christian faith in Jesus, worship, prayer, and daily communion with God. To this we added rest, Vitamin C, Zinc, and Magnesium.

Two days later, his symptoms were significantly improved. Of note, fever and headache had fully resolved. Cough persisted, but the shortness of breath was improving also. His wife did not have symptoms. However, we did not know for sure at this point whether it was COVID-19 or not, and we had concern for his wife and his return to work. After discussion, we decided to bring him in and run a test for COVID-19 as safely as possible. On March 19th, I collected the specimen myself (wearing appropriate Protective Equipment), while he stayed in his vehicle on our parking lot.

On March 21st, the results came back positive. Although this result was sobering, the circumstances were reassuring. He had continued to feel progressively better. Based on a review of the available medical literature and knowing that a clinical trial was beginning, I prescribed him Hydroxychloroquine 200 mg on top of the supplements he was already taking. I guided him in a low dose regimen, taking into account that he was already on the mend. He and I both eventually spoke with the County Health Department, and tracking of travel, contacts, and risk of exposure to all involved was performed admirably by their staff.

He was feeling even better on March 24th. Slight cough persisted with mild chest congestion. Fever, headache, and back pain remained fully gone. His wife had some mild symptoms, such as body aches, brief sore throat, mild sinus pressure, and her eye sockets felt tender. She improved after taking a low dose course of Hydroxychloroquine that I prescribed for her due to her definitive exposure to a confirmed case of COVID-19.

March 29th was the last day of his cough, and he was declared to be an official recovered case as of April 4th, about 3 weeks after the onset of his symptoms. His wife is doing well and never developed any significant fever, cough, or shortness of breath. Their outcome represents a good one, and in the face of rising incidence of fatalities and complicated cases, I believe it is helpful as a society for us all to remember that the vast majority of COVID-19 cases do have a good outcome.

As I stated earlier, COVID-19 may cause a broad spectrum of disease experience, differing from person to person. Each case must be managed individually, and the global medical community is striving to understand this virus and act wisely against it. Treating it with greater success requires listening to our patients and meeting them at their point of need, while applying expert knowledge of virology, pathophysiology, biochemistry, and pharmacology.

Indeed, we are all in this together. We were all created with identity, purpose, and talents to match the reason that we are here during this time and this season. We need each other, and we need the best that everyone brings to the table. As we press on, let’s work constructively together. We pray for each person reading this, however you’ve been affected… may you find the compassion, hope, trust and stability that you need. These are times that bring out our worst and our best. We hope that we will find you as we all continue to seek after that place of humility, grace, salvation, wisdom, peace, and connectedness that brings us together to good results.


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