Mycophenolate/prednisone

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 77-year-old man developed Coronavirus disease-19 (Covid-19) pneumonia during immunosuppressive treatment with mycophenolate and prednisone for refractory seropositive generalised myasthenia gravis [MG; routes not stated].

The man was admitted to the medical intensive care unit from another hospital after experiencing fever, respiratory distress and chills. Subsequently, he was diagnosed with COVID-19 pneumonia. His medical history was significant for hypertension, atrial fibrillation, congestive heart failure with reduced ejection failure and refractory seropositive MG diagnosed in 2019, along with severely slurred speech, dysphagia, drooling and eighty-pound weight loss over the past 6 months. At the time of diagnosis of COVID-19 pneumonia, he had been receiving prednisone 40mg daily, maintenance plasmapheresis and pyridostigmine. Additionally, he had also been receiving mycophenolate 1000mg twice daily, which was discontinued at the nursing home. It was also noted that, he had history of recurrent episodes of respiratory failure and sepsis, which required tracheostomy and percutaneous gastrostomy tube insertion.At admission, he was found to be tachypneic, tachycardic and his oxygen saturation was found to be 90%. On admission day 1, his chest X-ray showed bilateral air opacities, suggestive of multifocal infection. Subsequent laboratory work-up showed leukocytosis along with elevation in CRP, ferritin, lactic acid, procalcitonin, D-dimer and lactate dehydrogenase. At the night of hospital admission, non-invasive ventilation was initiated, following decannulation of the tracheostomy. On hospital day 2, his oxygen requirement was found to be increased to 15L. Based on the clinical symptoms and investigational findings, a diagnosis of Covid-19 pneumonia was made, which was determined to be related to the chronic immunosuppressive therapy (mycophenolate and prednisone) [durations of treatments to reactions onsets not stated].

Off-label treatment with IV dexamethasone 6mg was initiated (for a scheduled duration of 10 days) for the man's COVID-19 pneumonia, along with remdesivir. His blood culture showed growth of methicillin-resistant Staphylococcus aureus [aetiology not stated]. He thus underwent port removal. His echocardiogram demonstrated no vegetation or thrombus. Additionally, unspecified antimicrobials [antibiotics] were initiated for a total of 21 days. On hospital day 8, an improvement in his condition was noted, and he eventually recovered. He tolerated pressure support and was switched to a trach collar on day 9. Based on the clinical symptoms, an exacerbation of MG was also noted, which was thought to be related to COVID-19 infection. The exacerbation of MG was managed with a total of 5 sessions of plasmapheresis. On admission day 19, his tracheostomy was capped successfully and he was discharged to inpatient rehabilitation on day 21 with an improvement in his MG. His pyridostigmine and prednisone therapy were re-started. At 1 month follow-up after discharge, he was found to be in better condition.