Pulse Therapy with Corticosteroids in Covid-19 Pneumonia: A ‎Case Report‎

Pulse Therapy with Corticosteroids in Covid-19 Pneumonia: A ‎Case Report‎

Authors

  • Mohammad Rahmanian Anesthesiology, Critical care and pain management research center, Jahrom University of Medical Sciences, Jahrom, Iran.
  • Zhila Rahmanian Research center for social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran. https://orcid.org/0000-0002-7597-8295

Keywords:

Pulse, Corticosteroids, Pneumonia, COVID-19

Abstract

Introduction: The leading cause of death in patients infected with SARS-COV-2 is a combination of ‎acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC), which ‎leads to a fatal outcome in 11 to 15% of hospitalized patients. The present study reports a case of ‎successful high dose corticosteroids in the treatment of severe covid pneumonia. ‎

Case presentation: A 25-year-old patient with shortness of breath and a diagnosis of COVID-19 ‎referred to the emergency department of Peymanieh Hospital in Jahrom. Patient was complaining of ‎shortness of breath and cough that started 7 days ago that had gradually peaked. At arrival, saturation level ‎‎(O2sat) was 77% without fever. Lung computerized tomography (CT) revealed more than 90% involvement of lung lobes. Due to the patient's condition and hypoxia, and the patient's arterial ‎blood gases, he was transferred to the intensive care unit (ICU). Four days later he was intubated due to worsened breathing pattern and atrial gas analysis. The patient received ‎‎500 mg of methylprednisolone intravenously from 3rd day of ICU stay for three days, and 125 mg methylprednisolone ‎daily from the 7th to the 9th day of ICU care, and 8 mg daily dexamethasone for the rest of the administration. ‎Patient was extubated on 10th day of ICU stay and was discharged with an improved lung CT scan on the 20th day of administration.

Conclusion: Pulse therapy with corticosteroids with high doses of methylprednisolone was associated ‎with rapid elimination of respiratory failure and improvement in clinical manifestations and reversal of ‎pulmonary CT changes in a patient with COVID-19 with more than 90% lung involvement.‎

 

Learning points:

o   Pulse therapy with corticosteroids with high doses of methylprednisolone could improve ARDS quickly.

o   Pulse therapy might be considered for such cases not responding to other treatments. 

Declarations:

Acknowledgment:Clinical Research Development Unit of Peymanieh Educational and ‎Research and Therapeutic Center of Jahrom University of Medical Sciences has provided great facilities for ‎this work that here we appreciate.‎

Authors' Contributions:‎ MR and ZR were responsible physicians of the patient from the first day. Manuscript was written by ‎MR and ZR and ZR conducted the revisions. ‎

Conflict of interest:There are no conflicts of interest for any listed authors.

Funding: None.

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Full Text

Introduction

 

At the end of 2019, a number of patients with unknown symptoms of pneumonia were observed in ‎Wuhan (1). The disease caused by this virus called COVID-19 with an average incubation period of 3-7 ‎days is in most cases asymptomatic or with mild symptoms (80%) while cases of severe disease ‎require oxygenation (15%) and some cases of disease with consequences There are also serious people ‎who need a ventilator (5%) (2). The leading cause of death in infected patients worldwide is a ‎combination of ARDS and Disseminated intravascular coagulation (DIC), leading to a fatal outcome in 11 to 15% of hospitalized patients (3-4). ‎Therefore, it is essential to develop an effective treatment strategy to control the spread of the virus ‎and prevent cytokine storms. Corticosteroids can be used to suppress the cytokine storm and have ‎been used in some patients (5-8). The present study reported a case of corticosteroids in the treatment ‎of severe covid pneumonia.‎

Case presentation

A 25-year-old patient with shortness of breath and a diagnosis of COVID-19 presented to the emergency ‎department (ED) of Peymaniyeh Hospital. Clinical examination and history taking revealed that the patient's shortness ‎of breath and cough started 7 days ago and gradually symptoms peaked. Oxygen saturation (O2Sat) on arrival was 77% without fever and ‎ a family history of COVID-19. A positive Polymerase chain reaction (PCR) nasal swab for COVID-19 was obtained last week of presentation to ED. A lung computerized tomography (CT) was requested along with laboratory investigations of complete blood count (CBC), blood urea nitrogen (BUN), ‎ creatinine, blood electrolytes, Creatine phosphokinase (CPK), Lactate Dehydrogenase (LDH), blood sugar, liver function test, Prothrombin Time Test and INR (PT/INR), D dimer, fibrinogen level, and arterial blood gases (ABG) test. Lung CT scan showed more than 90% involvement of both lungs with ground glass opacities‎. He was requested to receive an intravenous serum therapy of 2500 cc of normal saline per day with 6-8 liters ‎of oxygen supplementation per hour by mask. Administration of remdesivir and Dexamethasone was started at hospitalization. Also, acyclovir was started, and the ‎patient was admitted to the ICU to be monitored according to his condition‏. ‏

Enoxaparin and ivermectin were started and cardiac and nutritional consultation was conducted. Blood culture was sent. Due to the lack of methylprednisolone in pharmacy, physicians started dexamethasone ‎for the patient and received extra normal saline due to low urinary output.

A cough cocktail containing salbutamol spray, ‎serotonin spray, diphenhydramine and dextromethorphan was added to the patient's medication, ‎which was discontinued due to the patient's hypersensitivity to diphenhydramine.

On the fourth day, patient developed acute respiratory distress with ‎ partial pressure of oxygen PO2 of 42.2 mm Hg. The patient was intubated by an anesthesiologist and propofol was prescribed for sedation. A urinary catheter and nasogastric tube (NG tube) were attached to the patient. Methylprednisolone was started ‎for the patient, but due to its unavailability, the patient has given dexamethasone every 8 hours and ‎meropenem every 8 hours. After examining the patient's ABG, a PEEP of ‎‎10 was given to the patient and feeding to the patient was started at 50 cc every four hours with NG. ‎Morphine and acetaminophen were started Azithromycin, vancomycin and Islamovir antibiotics were added to the patient's ‎drugs and chest physiotherapy was prescribed daily to better clear the infections from the ‎lungs‏.‏ Dimethicone, acyclovir, gabapentin, sertraline, and ‎azithromycin were discontinued, and ketotifen was added to improve sputum secretion. ‎ On 7th day, a hemoptysis happened and the pulmonologist insisted on finding methylprednisolone ‎for the patient and finally medication was provided and started. The patient received ‎‎500 mg of methylprednisolone intravenously in from 3rd day of ICU stay for three days, and 125 mg ‎methylprednisolone ‎daily from the 7th to the 9th day of ICU care, and 8 mg daily dexamethasone for the rest of the ‎administration. ‎Patient was extubated on 10th day of ICU stay and was discharged with improved lung CT scan on 20th  day of ‎administration. Proper oral corticosteroids were prescribed for tapering.

Discussion

The most common complication of COVID-19 is ARDS. The incidence of ARDS in critically ill patients is ‎reported to be up to 67%. When faced with a complex scenario of patients with severe COVID-19 ‎disease, a variety of protocols developed in different countries support complementary therapies, such ‎as antiviral therapy, recombinant human interferon, and corticosteroids (9). Several ‎studies have reported that the use of corticosteroids in diseases caused by other coronaviruses (such ‎as SARS-CoV-1 and MERS-CoV) will not be beneficial (10-11). The present study reported a case of ‎corticosteroids in the treatment of severe COVID-19 pneumonia. So et al. reported a group of seven ‎intubated COVID-19 patients treated with a 3-day pulse of corticosteroids (500 mg or 1 g of ‎methylprednisolone). All patients were extubated after treatment with corticosteroid pulse (2 to 7 days ‎of mechanical ventilation) and discharged from hospital (12). Pulse therapy with ‎methylprednisolone is often used in situations where it is necessary to quickly achieve an ‎immunosuppressive effect (13-16). If we use the equivalent dose of prednisone of more than 100 mg per ‎day (so-called pulse corticosteroids), we get the maximum effect from the genomic pathway and ‎additional responses faster than the "non-genomic pathway". These non-genomic mechanisms include ‎membrane dysfunction in all immune cells (including lymphocytes) that produce ATP by delaying the flow of ‎calcium and sodium channel membranes.

Other non-genomic effects are attributed to medicine binding to membrane GCR in T cells ‎‎(17) or release of the Src protein from the complex multigrain cGCR that all contribute to potential anti-inflammatory effects. This ‎action is fast (in hours) (18). In the present study, the patient received 500 mg of ‎methylprednisolone ampoule for the first three days of pulse therapy, 125 mg of methylprednisolone for the fourth to ‎sixth days, and 8 mg of dexamethasone for the seventh day. While the patient ‎had more than 90% lung involvement, he recovered and was discharged home without secondary ‎infection. Zhao et al. compared four treatments for patients with SARS-CoV pneumonia, including ‎different antibiotics, antivirals, and in some cases, corticosteroids in different doses. Only patients who ‎received methylprednisolone in doses above 160-1000 mg per day for 5 to 14 days had no mortality ‎and no need for mechanical ventilation (19). In a clinical trial, 34 patients with COVID-19 pneumonia ‎were randomly selected to receive methylprednisolone 250 mg daily for three days in comparison to 34 ‎patients under standard care. Patients with clinical improvement in the methylprednisolone group were ‎higher than the standard care group and the mortality rate was lower in the methylprednisolone group ‎‎(20). Yin Wang reported that intravenous administration of methylprednisolone at a dose of 1 to 2 mg / ‎kg / day for 5-7 days in COVID-19 patients with severe pneumonia was associated with a faster ‎improvement in clinical symptoms and an increase in SpO2 (21), which is consistent with the results of ‎the present study. However, in the reported patient, corticosteroid doses of 500 mg were used.‎

Conclusion‏:

‏ ‏Pulse treatment with high doses of methylprednisolone was associated with rapid elimination of ‎respiratory failure and improvement in clinical manifestations and reversal of pulmonary CT changes in ‎the COVID-19 patient evaluated with more than 90% of lung involvement‏.‏ While higher levels of evidence are needed for use of this treatment strategy in clinical setting. 

 

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Published

2022-08-11

How to Cite

Rahmanian, M., & Rahmanian, Z. (2022). Pulse Therapy with Corticosteroids in Covid-19 Pneumonia: A ‎Case Report‎. Updates in Emergency Medicine, 2(1), 67–70. Retrieved from http://uiemjournal.com/index.php/main/article/view/14
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