A case of afterload mismatch associated with shivering leading to fatal hypoxia in a COVID-19 patient

BACKGROUND: Fever and associated shivering are frequent symptoms in patients with coronavirus disease 2019 (COVID-19). High body temperature activates the immune system, which might be beneficial. However, shivering leads to high oxygen demand. CASE PRESENTATION: A 38-year-old man diagnosed with COVID-19 was transferred to our intensive care unit (ICU). His oxygen saturation (SpO2) level was approximately 92–95% and was managed with a high flow nasal cannula. Six hours after admission to the ICU, he started shivering, and his systolic blood pressure rose above 200 mmHg. Concomitantly, his SpO2 levels decreased rapidly. Mechanical ventilation was started, but oxygenation could not be maintained, requiring the establishment of extracorporeal membrane oxygenation (ECMO). CONCLUSIONS: COVID-19 is known to cause thrombosis in the pulmonary microvasculature at the early stage of the disease. Under these circumstances, caution should be paid since shivering may worsen the patient’s condition.