On 20th August 2022, an 80 year-old man presented in Reggio-Emilia Hospital with complaints of fever and asthenia. His past medical history included hypertension, past infiltrating prostate adenocarcinoma, psoriasis, and SARS-CoV-2 infection 6 months before. Since chest X-ray showed only peribronchovascular interstitial thickening and blood chemistry tests revealed only elevated levels of D-dimer (1376 ng/ml, range 10–500 ng/ml) and C-reactive protein (CRP, 3.87 mg/dl, range 0–0.5 mg/dl), he was discharged with oral antibiotic therapy (amoxicillin-clavulanate 875 mg/125 mg three times/day). However, on 21st August, he was readmitted to the Emergency Department for dyspnea and ataxia. Vital signs revealed body temperature (BT) 37.4 °C, blood pressure (BP) 100/55 mmHg, heart rate (HR) 102 beats per minute (bpm), and SpO2 90% on room air: oxygen therapy with Venturi Mask FiO2 40% was administered, with achievement of SpO2 95%. Electrocardiogram (ECG) documented sinus rhythm, right bundle branch, and either left anterior fascicular block. He was admitted to the infectious diseases unit: saline solution and empiric antibiotic therapy with piperacillin/tazobactam (2.5 g four times/day as renal dosage adjustment) and azithromycin (500 mg/day) was administered. Molecular swab for SARS-CoV-2, blood and urine culture, was collected before starting antibiotic therapy.

On 22nd August, the patient became soporous, anuric, with high BT (39.2 °C), hypotension (90/55 mmHg), metabolic acidosis, and respiratory failure, presenting clinical features of septic shock and multi organ failure. He was transferred to high care medicine unit, where piperacillin/tazobactam was replaced by meropenem (loading dose of 1 g, then 500 mg three times/day); volemic expansion, diuretic therapy, and continuous positive airway pressure were administered. Blood exams revealed normal leukocyte count, relative neutrophilia, and severe lymphocytopenia (leukocytes 7600/ul, neutrophils 99%, lymphocytes 1%), renal failure (high levels of creatinine 3.27 mg/dl, low glomerular filtration rate, eGFR 18.3 ml/min/1.73 m2), rhabdomyolysis (high levels of creatine phosphokinase 1323U/l, range 32–294U/l, and myoglobine 8843 ng/ml, range 0–110 ng/ml), hepatic cytolysis (high levels of aspartate transaminase 3880U/l, range 2–40U/l, and alanine transaminase 1414U/l, range 4–49U/l), cardiac damage (high levels of creatine kinase MB, CK-MB, 14.80 ng/ml, range 0–2.37 ng/ml, and troponine 4895.3 ng/l, range 0–57.3 ng/l), confirmed by the increased repeated cardiac enzymes (CK-MB 18.28 ng/ml and troponine 6809 ng/ml); ECG reported atrial fibrillation, rapid ventricular response, non-sustained ventricular tachycardia, and previous inferior myocardial infarction: digossine was administered. At the same time, an increase of CRP (40 mg/dl) and PCT (738 ng/ml) was observed: on 23rd August, clindamycin (900 mg three times/day) was added to meropenem, while on 24th August, doxycycline was administered, in order to extend the antimicrobial spectrum to gram-positive, intracellular, and anaerobic bacteria.

On 24th August, the patient was soporous, poorly responsive, presenting proximal tetraparesis and cyanosis of head and upper limbs. Total body computed-tomography was unremarkable, except for 2 cm bilateral pleural effusion and atelectasic thickening of the adjacent lung. Metabolic acidosis (pH 7.26) and anuria persisted: haemodialysis was performed, without volemic subtraction because of haemodynamic instability (BP 80/40 mmHg, HR 130 bpm); noradrenaline was administered. The patient died on 26th August.