Dexamethasone

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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 57-year-old man developed chronic cavitary pulmonary aspergillosis during off-label treatment with dexamethasone for COVID-19 pneumonia.

The man presented with cough, fever and breathing difficulty from two days. Medical history was significant for previously treated pulmonary tuberculosis 20 years back. On examination a HR of 100 beats/minute, RR of 24 breaths/minute, O₂ saturation of 84%, temperature of 100°F and bilateral crackles were noted. Laboratory investigations revealed leukocytosis followed by elevated levels of CRP, lactate dehydrogenase, ferritin and D-dimer. Reverse Transcriptase-PCR (RT-PCR) was positive for COVID-19, and chest X-ray revealed bilateral interstitial infiltrates along with a possible cavitatory lesion in the right upper zone. A high-resolution CT scan (HRCT) of the chest showed bilateral peripheral ground-glass opacities with right upper lobe cavity measuring 2.3 X 2.3cm and contained an opacity inside which was likely a fungal ball. A provisional diagnosis of severe COVID-19 pneumonia with a coexisting aspergilloma was made, and he was admitted to the ICU. Bi-level positive airway pressure and proning was initiated, and he received off-label IV dexamethasone [dosage not stated], remdesivir and unspecified anticoagulation. He was then shifted to the general ward on 6L oxygen, wherein he developed hypoxia on day three in the ward, and his O₂ requirement was increased to 15 L/minute. A repeat laboratory investigation revealed leukocytosis. However, the levels of CRP, D-dimer, ferritin, and LDH showed a decreasing trend. A repeat HRCT scan showed an increase in the right upper lobe cavity size to 3.3 X 3.2cm with an increase in the soft tissue ball to 12 X 8mm. Compared to the initial HRCT, the ground glass opacities were resolving. Based on the investigations, a possible invasion by the previously dormant aspergilloma, likely forming a semi invasive pulmonary aspergillosis was suspected. In Addition, serum galactomannan was elevated and aspergillus-specific immunoglobulin was positive. A diagnosis of chronic cavitating pulmonary aspergillosis was made based on the clinical, radiological, and biochemical parameters [duration of treatment to reaction onset not stated].

The man received treatment with voriconazole, along with the continuation of dexamethasone. Subsequently, he was weaned off from oxygen and dexamethasone was stopped. A repeat HRCT on day 23 of admission revealed disappearance of the fungal ball followed by reduction in the size of the cavity, and thinning of the cavity wall. RT-PCR for COVID-19 was negative, and he was discharged on vorniconazole. Two months later, he was asymptomatic, and he was advised to continue voriconazole treatment for two more months.