Migratory Pulmonary Infiltrates in a Patient With COVID-19 Infection and the Role of Corticosteroids

To the Editor:

The emergence of novel coronavirus disease 2019 (COVID-19) has led to a global pandemic and has threatened the lives of millions of people. This disease is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that results in respiratory failure, multiple organ dysfunction, and death.¹ Little is known about the spectrum of clinical presentations of COVID-19 in cancer patients.² Herein, we present a patient with chronic lymphocytic leukemia (CLL) who developed organizing pneumonia (OP) as a late manifestation of COVID-19 after an initial improvement who was successfully treated with corticosteroids.

Report of Case

A 62-year-old woman with CLL, hypertension, and type 2 diabetes mellitus presented with low-grade fever, cough, and shortness of breath of 1-week duration. Her CLL was treated with rituximab initially that was switched to ibrutinib 3 months earlier but was discontinued a few days before her hospitalization due to palpitations and arthralgia. On admission, she was hypoxic, requiring supplemental oxygen at 2 L/min to maintain oxygen saturation, SpO₂ > 93%, and in atrial fibrillation with no hemodynamic instability. Laboratory studies were significant only for elevated C-reactive protein at 74 mg/L (normal <10 mg/L). Nasopharyngeal swab specimen for reverse transcriptase-polymerase chain reaction for SARS-CoV-2 was positive, but negative for other respiratory viruses. Computed tomography scan of the chest showed bilateral ground-glass opacities (Figure A ). The patient was enrolled in the Mayo Clinic COVID-19 expanded access program for convalescent plasma (CCP) on day 9 of her illness and received one dose of CCP. The patient's respiratory status rapidly improved the day following CCP transfusion, maintaining SpO₂ on room air. After 3 days, the patient developed daily low-grade fevers and increasing shortness of breath requiring supplemental oxygen via nasal cannula. Infectious disease workup including blood cultures and fungal serum markers were negative. A repeat chest computed tomography, on day 17 of illness (Figure B), revealed new and migratory ground-glass opacities in both lungs that were consistent with an OP pattern. The patient was started on intravenous methylprednisolone at 1 mg/kg/d, which resulted in improvement in oxygenation and resolution of fever. She was discharged in stable condition after 7 days of corticosteroids.

Figure.

Axial computed tomography chest images on day 7 (day of admission, A) and day 17 after symptom onset (B), showing new and migratory lung infiltrates suggestive of organizing pneumonia.

Discussion

Our case may present a rare clinical course of COVID-19. Given the radiological appearance of migratory lung infiltrates and rapid improvement with corticosteroids, we hypothesize that this is OP due to the associated hyper-inflammation phase commonly seen in the later stages of COVID-19.³ Moreover, acute fibrinous and OP (a subtype of OP) are described in COVID-19, which could be the case in our patient, although it cannot be confirmed without a tissue biopsy.⁴ Although we conjecture that this is likely the explanation in our case, other plausible mechanisms of OP in our patient are 1) an immune activation-like phenomenon following cessation of ibrutinib or 2) augmentation of immune response by convalescent plasma.⁵ Bruton’s tyrosine kinase inhibitors are involved in toll-like receptor–mediated signaling and triggering of inflammatory cytokine and chemokine release.⁶ Ibrutinib, a highly potent inhibitor of Bruton’s tyrosine kinase, is considered to protect against lung injury in COVID-19.⁶

Corticosteroids are not currently recommended in the management of hospitalized patients with COVID-19 unless there is a separate indication such as asthma or chronic obstructive pulmonary disease or in intubated patients with acute respiratory distress syndrome.⁷ Organizing pneumonia as a delayed presentation of COVID-19 for which corticosteroids have significant benefit should be considered. Moreover, given the increasing use of convalescent plasma, OP as a possible downstream consequence should be investigated.