January-April 2023
UNIVERSA MEDICINA
Vol.42- No.1
pISSN: 1907-3062 / eISSN: 2407-2230
COVID-19 and the ageing immune system in
an elderly patient : a case report
Ida Ayu Pradnya Paramita1 and I Gusti Putu Suka Aryana2*
ABSTRACT
BACKGROUND
The severity of COVID-19 infection has an increasing trend in the elderly,
which contributes to the high morbidity and mortality rates in this
population. Aging itself is a prominent risk factor for severe disease and
death from COVID-19.
CASEDESCRIPTION
This case report a 71-year-old woman who complained of shortness of
breath for 3 days before being admitted to the hospital. Bilateral
consolidation and increased bronchovascular pattern were found on chest
radiograph, and a positive SARS-COV2 nasopharyngeal swab PCR test
result was noted. This patient was diagnosed with confirmed severe
manifestation of COVID-19, community-acquired pneumonia and type 1
respiratory failure, as well as type II diabetes mellitus and suspicion of
acute gastritis. The results of the geriatric status assessment were moderate
functional status, risk of malnutrition, and moderate risk of deep vein
thrombosis (DVT). This patient underwent treatment in accordance with
the COVID-19 protocol along with management for geriatric status
improvement. The patient was given permission to return home after 14
days of treatment, during which time her health had improved and her
functional status had changed to moderate dependency. During follow-
up, the patient continued to receive therapy. She is still being observed
and future evaluations will be conducted.
CONCLUSION
The increased susceptibility of the elderly to COVID-19 infection is caused
by various factors. A burden of death and long-term disability brought on
by this pandemic may be lessened by new or modified therapies that target
aging-associated mechanisms. Therefore, COVID-19 case management in
this population should be done with a comprehensive approach.
Keywords: COVID-19, geriatric, immunity, pneumonia, woman
1Medical Residency Program of
Internal Medicine,
Faculty of Medicine,
Universitas Udayana, Sanglah General
Hospital, Denpasar, Bali, Indonesia
2Department of Internal Medicine,
Faculty of Medicine,
Universitas Udayana,
Sanglah General Hospital, Denpasar,
Bali, Indonesia
*Correspondence:
I Gusti Putu Suka
Department of Internal Medicine,
Faculty of Medicine,
Universitas Udayana,
Sanglah General Hospital, Denpasar,
Bali, Indonesia
Email:
aryanaptsuka_aryana@unud.ac.id
ORCID ID: 0000-0001-8582-2254
Date of first submission, January 6, 2022
Date of final revised submission,
January 12, 2023
Date of acceptance, January 18, 2023
This open access article is distributed
under a Creative Commons Attribution-
Non Commercial-Share Alike 4.0
International License
DOI: http://dx.doi.org/10.18051/UnivMed.2023.v42:101-107
Copyright@Author(s) - https://univmed.org/ejurnal/index.php/medicina/article/view/1276
101
CASE REPORT
Cite this article as: Para mita IAP,
Aryana IGPS. ECOVID-19 and the
ageing immune system in an elderly
patient: a case report. Univ Med
2023 ;42 :101-7 . doi: 10.18051/
UnivMed.2023.v42:101-107.
mailto:aryanaptsuka_aryana@unud.ac.id
https://orcid.org/0000-0001-6560-4153
https://orcid.org/0000-0001-8582-2254
http://dx.doi.org/10.18051/UnivMed.2023.v42:101-107
https://univmed.org/ejurnal/index.php/medicina/article/view/1276
Paramita, Aryana COVID-19 geriatric immunity
102
INTRODUCTION
The COVID-19 pandemic that has spread
in almost all countries in the world requires clinical
and theoretical research related to various
populations with di ffer ent demographic
characteristics. Previous studies have reported
that chronic comorbi dities of diabetes,
hypertension, and c ardiovascular disease
aggravate the infectious condition of the SARS-
CoV2 virus.(1) Global molecular studies have
narrowed down the pathogenesis of this viral
infection to the interface between viral surface
proteins and ACE-II receptors on pulmonary
alveolar epithelial cells.(1,2) These findings are the
reasons for several other factors that strengthen
the findings regarding epidemiological data, which
generally state that the elderly population is the
group that is most affected by or most susceptible
to this infection, have a history of comorbidities,
and decreased numbers or polymorphisms of
ACE-II receptors.(2)
Data from the Centers for Disease Control
and Prevention (CDC) reports that although the
elderly population, or people over the age of 65,
only covers 17% of the total population in the
United States, this population accounts for up to
31% of total infections, 45% of hospital admission
rates, 53% of rates for intensive care, and 80%
of deaths due to COVID-19 infection.(3) In
Indonesia until early June 2020 it was shown that
the highest proportion of deaths was identified
among the elderly (43.8%). The mortality rate
indicated a similar trend in which the elderly
contributed to the highest rate (17.69%).(4) These
data indicate that the severity of COVID-19
infection tends to increase, resulting in higher
mortality or more severe clinical manifestations
in the elderly population.
Numerous case reports and studies on
COVID-19 cases that affect elderly people and
other vulnerable groups have been published.
These reports and studies demonstrate the
evidence of an aging immune system and a
decline in both its strength and function. A
number of changes to the body’s physiological
systems occur as a result of the complicated
phenomenon of aging. Immunosenescence, one
of the most significant changes, affects the
immune system. Given that aging is linked to high
rates of morbidity and mortality from numerous
diseases, the weakened immune function of the
elderly is clinically evident.(5) Immunosenescence,
or the loss of immune function and diminished
immunity to infectious pathogens with aging, is
brought on by intricate processes affecting immune
cell development and maintenance as well as the
origin, maintenance, and termination of
appropriately targeted immunological responses.(6)
However, the inc idenc e of post-
hospitalization COVID-19 complications, which
need additional follow-up and is related to the
maturation of the immune system against the
COVID-19 virus itself, cannot be explained by
the pertinent scientific data. Throughout this case
report, it will be clearly explained how to tackle
COVID-19 in elderly instances as well as how to
treat these patients properly after therapy. The
goal of this case report is to learn more about the
phenomena that arise in geriatric COVID-19
instances and call for a variety of therapeutic
stances. Based on the data above, the authors
are interested in knowing about the differences
in clinical symptoms as well as the impact of
treatment and therapy needed in the elderly with
COVID-19 infections.
CASE REPORT
A 71-year-old woman came to the hospital
complaining of shortness of breath for 3 days
before admission. She complained of coughing
up yellow phlegm since 3 days ago. She also
complained of fever for 3 days (less than 38C),
she merely laid in bed as she became weaker
and weake r. She had a sore throat and
experienced a decrease in appetite accompanied
by nausea and heartburn. Following questions on
secondary infections, cancer, or other related
diseases, the patient denied having any illnesses
that were related to immunocompromised
disorders.
103
The patient had a history of diabetes mellitus
since 2016, but she was not undergoing routine
treatment. Physical examination showed that the
body mass index (BMI) was 21.5 kg/m(2) and that
the patient was compos mentis. The blood
pressure was 130/80 mmHg, pulse rate 108 beats
per minute, respiratory rate 28 per minute,
temperature 37.8C, and oxygen saturation 90%
on room air. There were only additional crackles
heard in both lungs on auscultations.
There was consolidation in the upper and
lower zones of both lungs with increased
bronchovascular markings, an impression of
pneumonia (Figure 1). Clinical laboratory
findings are shown in Table 1. The patient was
d ia gn os e d a s h a vi ng se ve r e CO V ID -19 ,
community acquired pneumonia (CAP) and type-
1 respiratory failure, type-II diabetes mellitus,
and suspected acute gastritis. A comprehensive
geriatric assessment was mandatory, in which
the functional status using the activity of daily
living (ADL) Barthel index found the patient to
be moderately dependent and without delirium,
while from the assessment of nutritional status
the patient was found to be at risk of malnutrition.
She was in a state of mild cognitive impairment,
not depressed and had no incontinence. She was
at moderate risk for deep vein thrombosis using
the Wells Score System. She had low risk on
the Morse fall scale. She was in a pre-frail
condition and there was no failure to thrive.
Based on the Fracture Risk Assessment Tool
(FRAX) score, there was a moderate risk of
major osteoporosis. There was mild visual and
hearing impairment, but no physical disability.
The patient was placed in an isolation treatment
room and given oxygen therapy, dietary nutrition
at 1500 Kcal per day and 75 grams of protein
per day, levofloxacin 1x750 mg intravenously for
7 days, remdesivir loading dose 1 x 200mg
i nt r a ve nous l y on da y 1 a nd 1 x 10 0mg
intravenously on days 2-5, dexamethasone
2x5mg intravenously, paracetamol 3x500 mg
orally, omeprazole 2 x 40 mg intravenously,
vitamin C 2x500 mg, insulin Aspart 3x4 units
subcutaneously and insulin Glargine 14 units
every 24 hours subcutaneously and enoxaparin
subcutaneously 0.6 ml every 24 hours.
Th e r e we r e s e ve r al po s t-tr e a t me nt
situations that significantly improved in terms of
both general health and the findings of patient
examinations, including physical examinations
and laboratory tests, which also showed a
satisfactory improvement. Additionally, the
Figure 1. Thorax photo of the patient’s chest when she was first admitted to the hospital
Univ Med Vol. 42 No. 1
Paramita, Aryana COVID-19 geriatric immunity
104
patient was monitored more closely while
receiving care at home, and her condition
improved. The patient was informed of the
scientific and clinical interest in her disease as
well as of this anonymous publication. She gave
informed verbal consent to the anonymous
publication.
DISCUSSION
According to a study, elderly people are
more frequently affected by SARS-CoV-2
infection than are people of younger ages, and
Test Parameter Values
Complete blood count
WBC (103/µL)
Neu (103/µL)
Lym (103/µL)
Mono(103/µL)
Eos (103/µL)
Baso (103/µL)
5.16
4.42
0.49
0.23
0.01
0.01
Hb (g/dL) 11.61
Hct (%) 34.23
MCV (fL) 83.93
MCH (pg) 28.47
MCHC (%) 31.29
PLT (103/µL) 356.70
Blood chemistry
SGOT (U/L) 53.0
SGPT (U/L) 30.0
BUN (mg/dL) 25.90
SC (mg/dL) 1.06
e-GFR 124.04
Albumin (g/dL) 3.30
Blood glucose (mg/dL) 245
HbA1c (%) 13.6
Total Cholesterol (mg/dL) 178
HDL (mg/dL) 37
LDL (mg/dL) 116
Triglycerides (mg/dL) 140
Electrolytes
K+ (mmol/L) 4.10
Na+ (mmol/L) 131
Blood gas analysis
pH 7.41
pCO2 38.7
pO2 88.8
Base excess (g/dL) 3.3
HCO3- 24.1
SO2 (%) 89
Real Time-PCR Reactive
Table 1. Clinical laboratory findings of the patient
e-GFR: glomerular filtration rate; BUN, blood urea nitrogen; Hb: hemoglobin; Hct: hematocrit; HDL: high-density lipopro-
tein; LDL: low-density lipoprotein; MCV: mean corpuscular volume; MCH: mean corpuscular hemoglobin; MCHC: mean
corpuscular hemoglobin concentration; PLT: platelets; SC: serum creatinine; SGPT: serum glutamic pyruvic transaminase;
SGOT: serum glutamic oxaloacetic transaminase; WBC: white blood cells
this association is more frequently negative.(7)
Based on a retrospective analysis of 85 patients
who had died in Wuhan from SARS-CoV-2
infection, the patients’ median age was 65.8
years.(8) Numerous immune system biochemical
changes brought on by aging are associated with
age-related disorders and increased vulnerability
to communicable diseases. Senescent immune
cell accumulation contributes to the immune
system’s decline as it ages, while concurrently
increasing inflammatory phenotypes lead to
immunological dysfunction. These two processes
are known as immunosenescence.(9)
105
Atypical symptoms found in elderly patients
with COV ID-19 are de lirium, low-grade
hyperpyrexia, and abdominal pain.(10) A consensus
from The Infectious Disease Society of America
recommends guidelines for the definition of fever
in the elderly, namely the result of measuring an
oral temperature of more than 37.8oC.(11)
The presence of DNA methyltransferase
inhibition in Treg cells can accelerate the
resolution of lung injury in younger persons,
whereas in the elderly there is hypermethylation
o f Tr e g ce l l DN A d u e to mito c h on dr i a l
dysfunction caused by the accumulation of toxic
metabolites and reactive oxygen species in this
population.(12) There are differences in ACE-II
levels in lung tissue compared to the young
population, which according to several studies
showed a decrease in ACE-II expression in the
e l d e r l y popu l a t i on . ( 1 0 , 1 3 ) ACE -II ge n e
polymorphism was also found in exon 19 of
chromosome X p.22.2 in the elderly. One
polymorphism that is known to increase mortality
in the elderly with COVID-19 is the deletion of
intron 16 in the ACE-II gene.(2) T cells play a
role in the adaptive ability of immunity to increase
antigen-specific memory T cells, which can
predispose to the development of severe
COVID-19 infection, increased length of
hospitalization and the occurrence of acute
respiratory distress syndrome (ARDS).(12)
The population sh ows a continuous
production of inflammatory mediators and
cytokines which is often known as inflammaging.
Expression of Toll-like receptor (TLR) may
increase but the function of the T cells decreases,
so that the antigen presenting cell (APC)
response in the face of viral infection becomes
inappropriate which ultimately triggers excessive
cytokine pr oduction. (1 0,1 4) Aging-r elated
immunosenescence is associated with chronic
secretion of pro-inflammatory cytokines known
as senescence associated secretory phenotype
(SASP). Accumulation of SASP cells during aging
can lead to persistent withdrawal and activation
of effector immune cells, which impairs local
communication betwee n pro- and anti-
inflammatory systems, leading to tissue damage
and incorrect tissue repair.(12)
The administration of chloroquine in the
elderly must be very closely monitored regarding
its lethal effects through increased QT interval
and hypoglycemia. Administration of tocilizumab
is contraindicated in the elderly with a history of
diabetes, bacterial infection and the use of
corticoste roids, to avoid superimposed
infection.(10,15,16) Patients with complications of
sepsis accompanied by a D dimer level of 3 g/
mL and a coagulation score of >4 can be given
anticoagulant thera py with direct or al
anticoagulant (DOAC) to prevent thromboembolic
events.(10)
In elderly patients infected with COVID-
19, the inflammatory reaction produced on the
surface of the lung epithelium makes it difficult
to remove the bacteria so that secondary bacterial
infections often occur and can worsen the
prognosis.(1,3,16) Based on the National Institute
for Health and Care Excellence (NICE)
guidelines, the administration of antibiotics to the
elderly over the age of 75 years with COVID-19
infection who have pneumonia due to secondary
bacterial infection, should take place at least 4
hours after the onset of infection.(16)
The use of corticosteroids is controversial
in viral infections due to their immunosuppressant
effects.(17) In addition, it should be noted that the
use of steroids in the elderly could have metabolic
effects that could trigger comorbidities in the
elderly such as hypertension, diabetes, bone
fractures and cataracts.(10,18)
Nutrition plays an important role in the
management of COVID-19 infection in the
elderly, where good nutrition will help improve
the immune system of the elderly.(19,20) Most of
the elderly suffer from nutritional disorders,
especially malnutrition. The caloric requirement
in patients aged over 65 years with multiple
comorbidities is 20 to 30 kcal/kgBW/day whereas
the target of 30 kcal/kgBW/day should achieved
slowly over 3 to 4 days to avoid the risk of
refeeding syndrome. Protein needs in the elderly
with COVID-19 infection should be higher due
Univ Med Vol. 41 No 2
Paramita, Aryana COVID-19 geriatric immunity
106
to increased protein catabolism due to pro-
inf lammatory media tor s wher e protein
requirements are estimated to be 1g/kgBW/day
– 1.5g/kgBW/day. The recommended ratio of fat
to carbohydrates is 30:70 in patients without
respiratory deficiency and 50:50 in patients who
use ventilation.(20,21) Immunosenescence in elderly
patients can be triggered by malnutrition.(14,20)
Micronutrient intake in the elderly infected
with COVID-19 must exceed the recommended
daily intake because infectious conditions can
reduce the body’s mi cronutrient leve ls.
Micronutrients that must be considered include
vitamin C which functions in increasing the
immune system which is recommended to be
consumed at 24g/day for 7 days. Zinc deficiency
can increase the risk of infection, where studies
examining the effects of zinc administration show
that zinc supplementation can increase natural
killer cell activity through increased expression
of perforins.(22)
Our patient was observed to be in good
health and to be devoid of COVID-19-related
comorbidities and sequelae at the post-treatment
check-up. Although complaints including
weakness and occasionally dizziness still exist,
they are more likely to be caused by the influence
of multiple additional co-morbidities than because
of COVID-19 directly. Elderly care at home has
an important role in treating COVID-19 in the
elderly. The related facilities must prepare several
pharmacological therapies that can be used for
the elderly experiencing COVID-19 infection.
Mortality of the elderly with COVID-19 is higher
in nursing home facilities than in hospitals so that
service providers must be prepared about
administering drugs that can help relieve suffering
before death..(11) In the case of elderly living in
isolation from daily activities without access to
communication with their families, this can lead
to a worsening of their perception of reality,
changes in sleep patterns, and delirium. Service
providers for the elderly must be ready with
psychological support for their patients during this
pandemic to minimize the incidence of depression
in these elderly.(12)
CONCLUSION
Information on COVID-19 immunopathology
is still limited and our understanding of the disease
is evolving rapidly. Thus, the current evidence
may soon change with the accumulation of new
knowledge of SARS-CoV-2 biology and host
immune responses. Assessment of geriatric status
must be carried out comprehensively and the
complexity of management in elderly patients
infected with COVID-19 needs to be carefully
considered.
CONFLICT OF INTEREST
The authors report no conflicts of interest
in this work.
ACKNOWLEDGEMENT
The authors would like to thank all
colleagues who contributed with the exchange
of experiences, information, and discussion to this
case report
FUNDING STATEMENTS
The authors receive no grants during this
study conducted.
AUTHOR CONTRIBUTIONS
IGPSA contributed to diagnosis and was
responsible for the management of this patient.
IAPP contributed to revision of the manuscript.
Both authors contrib uted equally to the
presentation of the case report. All authors have
read and approved the final manuscript.
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