THE BENEFITS OF CORTICOSTEROIDS IN COVID-19 WITH ORGANIZING PNEUMONIA-LIKE PATTERN: A CLINICAL REPORT OF SUCCESSFUL TREATMENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Since the outbreak of COVID-19 (disease caused by severe acute respiratory syndrome coronavirus 2 - SARS-CoV-2), the world faces a major public health crisis.Organizing pneumonia (OP) is a relatively rare condition, that can be idiopathic or, more commonly, result from infections, drugs or autoimmunity (secondary OP) #1. Viral induced OP throughout the severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and H1N1 viral pandemics was well documented #2. The reported imaging findings of COVID-19 suggest that secondary OP may be occurring even more often #2. CASE PRESENTATION: 74-y-old man, evaluated in the emergency room for dry cough and asthenia with 1 week of evolution. He presented with hypoxemic respiratory failure (PaO2/FiO2 ratio: 276), and tested positive for SARS-CoV-2, being admitted in the COVID department. Treatment with Dexamethasone 6mg was started but a week later (day 14 of illness) there was a clinical deterioration, with worsening of the respiratory insufficiency (PaO2/FiO2 ratio: 175), requiring introduction of non-invasive mechanical ventilation with high oxygen rates. A clinical and gasometrical improvement (PaO2/FiO2 ratio: 230»253) was then observed with slow reduction and weaning from corticosteroids at D10 of dexamethasone. At day 20 of the disease, there was a new clinical and gasometrical worsening (PaO2/FiO2: 162), and it was decided to restart dexamethasone 6mg. No clinical improvement was observed in the following days and a chest computed tomography (CT) was performed, revealing multiple peripheral areas of consolidation and bilateral ground glass opacities, suggestive of an OP-like pattern. Given these findings, the case was discussed in a multidisciplinary team reunion, who considered the diagnosis of OP secondary to COVID-19 infection. It was decided to initiate 'pulse-dose' methylprednisolone 1000mg IV for 3 days and posteriorly the dosage of steroids was tapered every 3 days. There was an abrupt reduction in oxygen and ventilatory support needs and he was discharge requiring only 1L of oxygen and showing significant radiological improvement. After 3 months of follow-up, chest CT scan revealed dramatic improvements regarding previous findings. DISCUSSION: The definitive role of SARS-CoV-2 infection in diffuse lung injury is still unclear, but it is expected that it might induce host immune responses that damage the lungs. Corticosteroids, as immunosuppressive and anti-inflammatory agents, can reduce lung damage by regulating various inflammatory responses #3. CONCLUSIONS: This case suggests that corticosteroids may be an option to consider in COVID-19 pneumonia with an OP-like pattern. Secondary OP often requires prolonged corticosteroid treatment. It is important to increase recognition of this diagnosis, in order to start the appropriate treatment, which may lead to a reduction of the harmful consequences of COVID-19. REFERENCE #1: Drakopanagiotakis F, Paschalaki K, Abu-Hijleh M, Aswad B, Karagianidis N, Kastanakis E, Braman SS, Polychronopoulos V. Cryptogenic and secondary organizing pneumonia: clinical presentation, radiographic findings, treatment response, and prognosis. Chest. 2011 Apr;139(4):893-900. doi: 10.1378/chest.10-0883. Epub 2010 Aug 19. PMID: 20724743. REFERENCE #2: Kory P, Kanne JP. SARS-CoV-2 organising pneumonia: 'Has there been a widespread failure to identify and treat this prevalent condition in COVID-19?'. BMJ Open Resp Res 2020;7:e000724. doi:10.1136/ bmjresp-2020-000724 REFERENCE #3: Fauci AS. Mechanisms of the immunosuppressive and anti-inflammatory effects of glucocorticosteroids. J Immunopharmacol. 1978;1:1-25. DISCLOSURES: No relevant relationships by Mariana Argel, source=Web Response No relevant relationships by Joana Correia, source=Web Response No relevant relationships by Marta Sousa, source=Web Response No relevant relationships by António Torres, source=Web Response