A Tale of Two Twins: Discordant Presentation of COVID-19 in Identical Twins

Coronavirus disease 2019 (COVID-19) is a highly contagious viral illness caused by the RNA virus Coronaviridae subtype severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Rapid infection caused by this virus became overwhelming and resulted in millions of deaths worldwide. The effects of smoking have been heavily studied and lead to increased occurrence of COVID-19 viral infections and mortality. The phenomenon of cytokine storm has been shown as one of the leading factors of mortality. However, the question remains as to what factors, either genetic or environmental, ultimately lead to the increased incidence of cytokine storms compared to others. We present a case of two cohabitating, 57-year-old, male, identical twins (Twin A and Twin B) who contracted SARS-CoV-2 simultaneously. Both Twin A and Twin B had similar medical histories, except for Twin A being a former smoker while Twin B a current smoker. While both twins presented with cough and shortness of breath, Twin A also presented with hypoxia, leukocytosis, evidence of acute kidney injury, and transaminitis while Twin B presented normoxic with solely tachycardia. Due to his presentation and vital signs, Twin B received Bamlanivimab but developed hypoxia during the infusion. Both twins were subsequently initiated on Remdesivir, dexamethasone, and supplemental oxygen daily. After completion of treatment courses, both twins had improvement in their laboratory values and were subsequently discharged with supplemental oxygen to be further weaned in the outpatient setting. Due to the twins' cohabitation, contracting SARS-CoV-2 simultaneously, and similar medical history, we highlight the potential mechanism of nicotine's chemical ability to blunt the subsequent inflammatory process of COVID-19. Despite nicotine's potential ability to dampen cytokine storms, smoking has well-documented adverse effects and we, like many experts, entirely discourage it. However, given the rare situation of identical twins contracting SARS-CoV-2, we can extrapolate information regarding the effects of the virus without obfuscation from genetic and environmental factors to identify areas of research for new therapies.