SESSION TITLE: Medical Student/Resident Chest Infections Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: Coronavirus disease- 2019 (COVID-19) is a novel disease caused by the beta-coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It was declared a pandemic by the world health organization (WHO) on March 11, 2020.[1] At the time of writing this, there are more than one million confirmed cases of COVID-19 worldwide and the disease has claimed over ninety thousand lives. Currently, there are no food and drug administration (FDA) approved medications to treat this disease. We present a rare case of COVID-19 exacerbated by existing right diaphragm hemiparesis and possibly a myasthenic crisis which was successfully treated with hydroxychloroquine, tocilizumab, pyridostigmine, steroids and intravenous immunoglobulin (IVIG).
CASE PRESENTATION: Our Patient is a forty-four-year-old male with a prior medical history of hypertension, hypothyroidism, myasthenia gravis and right diaphragm hemiparesis. He presented to our emergency department with worsening cough, fever and dyspnea after being discharged from an outside hospital for the treatment of community acquired pneumonia with empiric antibiotics. He was hypoxic and tachypneic with a low vital capacity. His chest x-ray was suggestive of multifocal pneumonia and he tested positive for SARS-CoV-2. He was intubated in the Medical Intensive Care Unit (MICU) for hypoxic and hypercapnic respiratory failure caused by COVID-19 pneumonia and existing right diaphragm hemiparesis. It was also thought that his diaphragm hemiparesis was possibly exacerbated by a myasthenic crisis in the setting of a viral illness and recent use of azithromycin. During his hospital stay, the patient was managed with lung protective ventilation for severe acute respiratory distress syndrome (ARDS). He was treated with hydroxychloroquine, tocilizumab, pyridostigmine, steroids and IVIG. On day nine of admission, his oxygen requirements started decreasing and the patient self-extubated the next day. He was subsequently discharged in stable condition.
DISCUSSION: Current guidelines suggest against the use of steroids in COVID-19, except in the setting of ARDS or refractory shock. It is also currently recommended to avoid IVIG for the treatment of COVID-19 due to the risk of side effects with lack of demonstrable benefit. [2] While it is difficult to attribute the recovery of our patient to any single intervention, we feel that this case should ease some of the trepidation faced by intensivists when needing to start immunomodulatory therapy for a comorbid condition in the setting of COVID-19.
CONCLUSIONS: COVID-19 must not preclude the use of immunomodulatory therapies such as steroids and IVIG if indicated for a comorbid condition and given the hyper-inflammatory state of this disease, immunomodulatory therapies deserve consideration for the treatment of COVID-19.
Reference #1: World Health Organization. Coronavirus disease 2019 (COVID-19): situation report, 67.
Reference #2: Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Medicine. 2020 Mar 28:1-34.
DISCLOSURES: No relevant relationships by Mohammad Islam, source=Web Response
No relevant relationships by VICTOR PRADO, source=Web Response
No relevant relationships by Sairam Raghavan, source=Web Response