PCR SARS-CoV-2 showed positive result. The patient received aseptamivir at a dose of 150 mg, levofloxacin at a dose of 500 mg, chloroquine at a dose of 1000 mg and vitamin C as treatment.

The patient was discharged from our hospital after three weeks with clinically stable and referred to COVID-19 center hospital nearby his home for another two weeks. After PCR SARS-CoV-2 was performed twice showed negative results, the patient was discharged. Recently published COVID-19 studies have shown that SARS-CoV-2 infection was more likely to occur and seem to have a heightened vulnerability to develop COVID-19 and tend to have more severe disease with worse clinical outcomes in patient with underlying cardiovascular disease (CVD).^{2, 3}

However, there is no case report that clearly suggests that COVID-19 can cause Acute Coronary Syndrome (ACS). Patient with artery coronary disease at risk the occurrence of coronary plaque rupture secondary to virally induced systemic inflammation. The mechanism of acute myocardial injury caused by COVID-19 might be related to angiotensin converting enzyme 2 (ACE2). The interaction between SARS-CoV2 and ACE2 can result in changes of ACE2 pathways leading to acute injury to the heart, lung and endothelial cells.^{4, 5}

In this case, theoretically, COVID-19 may induced STEMI due to systemic inflammation but we need further study to confirm direct relation between STEMI and COVID-19. The patient was admitted in our hospital 2 weeks from the first confirmed COVID-19 in Indonesia. The awareness of the sign and symptoms and logistic diagnostic tools was limited at the time but the clinical feature of this patient, massive and thick mucus productivity suspect the diagnosis of COVID-19.

The pathology of COVID-19 also shows fibromyxoid exudation and the formation of thick “mucus plugs”. A large amount of sticky secretions spilling out of the alveoli, with fibrous cords visible was found in the first autopsy.⁵ This case report emphasize that a thick mucus plaque with stool cell may be a specific clinical features in COVID-19 patients.

Tracheostomy is an aerosol-generating procedure, so health-care workers are at risk of infection during insertion and subsequent care, even when appropriate personal protective equipment (PPE) is used. Ensuring adequate PPE, to maintain the safety of the health-care team, is among the foremost considerations in decisions around the management of patients with COVID-19 in the ICU.

The major indication for tracheostomy remains the facilitation of mechanical ventilation for a long period, while minimizing complications from a translaryngeal endotracheal tube and weaning from ventilation. Tracheostomy might also be required for actual or threatened airway obstruction, laryngeal edema (which might be an emerging feature of COVID-19) or unsuccessful extubation due to weakness, poor cough, tenacious secretions, or a combination of these factors. Because tracheostomy is an aerosol-generating procedure and recognizing that many health-care facilities lack negative pressure rooms, portable high-efficiency particulate air filtration systems might be an acceptable alternative.