Justification of treatment and possible outcomes of severe COVID-19

The role of hyaluronic acid in the pathogenesis of acute respiratory distress syndrome, including those associated with severe COVID-19, is known. Pro-inflammatory cytokines (interleukin-1, tumor necrosis factor) are strong inducers of hyaluronic acid synthase (HAS2) in CD31+ endothelial cells, EpCAM+ cells of the alveolar epithelium of the lungs and fibroblasts. Hyaluronic acid can absorb water in quantities significantly exceeding its own molecular weight. Reducing the presence or inhibiting of hyaluronic acid synthesis is of great importance for facilitating the breathing of COVID-19 patients. Hyaluronidase-based preparations can reduce the accumulation of hyaluronic acid and promote pulmonary alveoli cleansing. Respiratory viral infections, including pandemic strains of coronaviruses, especially in severe cases with acute respiratory distress syndrome, can be complicated by the development of pulmonary fibrosis. It has been shown that changes in X-ray Computed Tomography findings characteristic of fibrosis in the first year after COVID-19 can significantly regress. A clinical case from the practice of treating a patient with a severe course of COVID-19, significant cardiovascular comorbidity, grade 2 obesity, which was regarded as significant risk factors for an unfavorable outcome, is presented. The patient with signs of progressive respiratory failure was admitted to the intensive care unit. Pulse therapy with glucocorticosteroids and anticoagulants was started. Deterioration of the condition is regarded as the beginning of acute respiratory distress syndrome, which complicated the cytokine storm induced by the coronavirus. The patient was taken for high-flow oxygenation. An anti-cytokine therapy was prescribed. Reduction of inflammatory markers was obtained, but severe respiratory failure persisted. The bovgialuronidase azoximer was included in the treatment. The patient's condition began to stabilize then she was discharged in stable condition without oxygen support. The available data on the negative role of hyaluronic acid in the pathogenesis of acute respiratory distress syndrome in patients with COVID-19, as well as the need to reduce the likelihood of developing residual fibrous changes in the lungs in patients who have undergone acute respiratory distress syndrome, suggest the need for further studies of domestic azoximer bovgialuronidase properties in the treatment of severe forms of COVID-19.