Case presentation
A 36-year-old male shepherd living in rural areas of Kermanshah, Iran, presented to the emergency department with fever, myalgia, and abdominal pain for 3 days prior to admission. His initial complaints did not mention cough, dyspnea, hematemesis, melena, or hematuria. His medical history was insignificant. Physical examination was normal, and his vital signs were stable except for a low-grade temperature at admission. His oxygen saturation was 96% on ambient air. Due to the COVID-19 pandemic and suspicion of SARS-CoV-2 infection, he was immediately put in an isolation room, his nasopharyngeal swab specimen was sent for a SARS-CoV-2 RT-PCR test, and he underwent a computed tomography (CT) scan of the chest. The patient was started on favipiravir, dexamethasone, and heparin. No pulmonary evidence of SARS-CoV-2 was detected in the lung imaging, and his laboratory tests were in the normal range, except for an elevated CRP level. However, within three days of hospitalization, he developed progressive thrombocytopenia and increased elevated transaminases and LDH. However, coagulation tests were not impaired, fortunately.
Moreover, he developed a petechial rash on his buttocks. Anticoagulant therapy was stopped, and platelet infusion was started for him. Considering the summer season, the patient’s occupation, epidemiologic features, bleeding syndrome, severe thrombocytopenia, and elevated liver enzymes, this patient was highly suspected of CCHF. Hence, a blood PCR test for CCHFV was also requested, and he was started on ribavirin with dosing according to WHO recommendations and the national clinical protocol of Iran for CCHF. The interesting issue was the result of his positive PCR tests for both SARS-CoV-2 and CCHFV. The patient’s condition improved, and was discharged 8 days after admission.