P5‐44: Pulmonary nontuberculous mycobacterial infection in patients with rheumatoid arthritis on biological therapy

declared as a global pandemic. It presents with respiratory symptoms and subsequently evolve as a multisystem disease with a gamut of complications owing to a phenomenon known as cytokine storm. Hyperpyrexia is one such lethal complication of COVID-19 which is extremely rare in pregnancy. Case Presentation: We report a 24 year old nulliparous Asian in her 2nd trimester of pregnancy who presented with severe COVID-19 pneumonia. Despite optimal management including airway support, steroids, anticoagulation and antimicrobial cover patient deteriorated necessitating mechanical ventilation on 4th day of illness. Two doses of intravenous tocilizumab were commenced. Her clinical and biochemical parameters were on an improving trend thereafter. However on 10th day she developed a continuous high grade fever which poorly responded to antipyretics and dantrolene. She didn’t have clinical or laboratory results to indicate a septic focus, neuroleptic malignant syndrome or malignant hyperthermia. Interleukin 6 (IL-6), ferritin and lactate dehydrogenase levels were elevated while d-dimers were persistently negative. She succumbed to her illness on 10th day. Discussion: Hyperpyrexia is defined as fever of more than 41.5 C due to an abnormally raised hypothalamic thermoregulatory set point. Exact mechanism behind hyperpyrexia in COVID-19 in unknown. Postulated theories include direct viral damage to hypothalamus, surge of cytokines and disseminated thrombogenicity. In our patient cytokine surge was the probable culprit evidenced by raised IL-6 levels. However further studies should be beneficial in identifying exact pathophysiology to treat this grave complication as it carries a poor prognosis.