The silhouette sign is a commonly used radiological terminology, useful in diagnosis. The term is a misnomer and the loss of silhouette sign is what is to be mentioned. Whenever there is a loss of silhouette sign in a chest radiograph the differential diagnosis of consolidation, pleural effusion, collapse. etc., needs to be considered.

We report a case of coronavirus disease 2019 (COVID-19) infection in a patient with multiple comorbidities diabetes, hypertension, ischemic heart disease, and chronic liver disease. Although pleural effusion is rarely seen in COVID-19 infection, the presence of which should be interpreted carefully. In this case report, our patient presented with complaints of fever, cough, and dyspnea, and focused clinical examination revealed fullness in the left hemithorax compared to right; reduced chest movements in the left hemithorax and trachea deviated to the right; dullness in the left hemithorax and right infrascapular, infra-axillary, and mammary area; and absent breath sounds in areas where dullness was noted. A chest X-ray done revealed left massive pleural effusion with right mild pleural effusion and pleural fluid analysis on both sides revealed transudate picture; this was also similar to the ascitic fluid analysis that was done in this patient; at this point of time, a computed tomography of the thorax was done to rule out other causes of pleural effusion. Meanwhile, other laboratory investigations revealed evidence of liver cell failure showing hyperbilirubinemia, hypoalbuminemia, and deranged prothrombin time and international normalized ratio (INR) and imaging evidence of cirrhotic liver; the patient was treated accordingly. Therapeutic pleural tapping was done after INR normalized; the patient improved symptomatically. Pleural effusion although is a rare manifestation of COVID-19, the etiologies are varied, it is important for us to consider other possible comorbidities associated in a patient who is hospitalized for acute illness, in this case, the patient had multiple comorbidities such as diabetes, hypertension, ischemic heart disease, and chronic liver disease, and the cause for pleural effusion is attributed to decompensated chronic liver disease and ischemic heart disease. In this case, the acute infection has resulted in the decompensation of his preexisting chronic disease.

Background: Severity of COVID 19 disease is related to the systemic inflammatory response triggered by the respiratory virus. Hematological alterations triggered by inflammation can be used as a marker to predict the severity of COVID 19 infection.Methods: 155 patients of severe acute respiratory infections (SARI) defined by World Health Organization (WHO) criteria of which 65 were COVID positive and 90 COVID negative were taken for the study. Demographic profile of the population and platelet count, lymphocyte count and platelet lymphocyte ratio was compared between COVID 19 positive and negative SARI cases using appropriate descriptive statistics. Correlation analysis done for the same parameters between severe and moderate COVID 19 SARI cases.Results: Median platelet count in COVID positive group (2.47 L) was lower than that of COVID negative group (2.65 L) and was not statistically significant between 2 groups. Median lymphocyte count in COVID positive group (651) was lower compared to the negative group (1250) and difference was statistically significant. PLR in COVID positive group was higher (353) than COVID negative group (198) and was statistically significant (p value 0.00). PLR was higher in severe COVID disease compare to moderate disease but difference was not statistically significant. No significant correlation was found in platelet count, lymphocyte count in moderate and severe COVID positive SARI cases.Conclusions: Lower lymphocyte counts was observed in SARI caused by COVID 19 infection than other causes of SARI. No significant correlation was found in platelet count between COVID positive and negative SARI cases. PLR was significantly higher in COVID positive SARI cases as compared to COVID negative SARI cases. Platelet lymphocyte ratio (PLR) was higher in severe COVID disease when compared to moderate disease but levels did not reach statistical significance.