key: cord-0781063-iacw17ah
authors: Inoue, Hideki; Jinno, Megumi; Ohta, Shin; Kishino, Yasunari; Kawahara, Tomoko; Mikuni, Hatsuko; Sato, Haruna; Yamamoto, Mayumi; Sato, Yoko; Onitsuka, Chisato; Goto, Yuiko; Ikeda, Hitoshi; Sato, Hiroki; Uno, Tomoki; Uchida, Yoshitaka; Kimura, Tomoyuki; Miyata, Yoshito; Hirai, Kuniaki; Homma, Tetsuya; Watanabe, Yoshio; Kusumoto, Sojiro; Suzuki, Shintaro; Tokimatsu, Issei; Tanaka, Akihiko; Sagara, Hironori
title: Combination treatment of short-course systemic corticosteroid and favipiravir in a successfully treated case of critically ill COVID-19 pneumonia with COPD
date: 2020-08-27
journal: Respir Med Case Rep
DOI: 10.1016/j.rmcr.2020.101200
sha: ca597de8e5fcb659efe80378f94c96667011bb6b
doc_id: 781063
cord_uid: iacw17ah

Use of systemic corticosteroids for the treatment for coronavirus disease 2019 (COVID-19) among chronic obstructive pulmonary disease (COPD) patients is not well described. A 58-year-old man with fever and progressive dyspnea was admitted to the Showa University Hospital, and showed severe respiratory failure which needed mechanical ventilation. His chest computed tomography scanning showed emphysema and bilateral ground-glass opacity caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. He received 30 mg prednisolone for five days with antiviral drug of favipiravir, and was successfully extubated on day five. A SARS-CoV-2 polymerase chain reaction (PCR) test became negative on day 15. He was discharged on day 21. Serum IgM and IgG antibodies against SARS-CoV-2 converted to positive on day 7 and they kept positive on day 54 for both IgM and IgG. Combination treatment of short-course systemic corticosteroid and favipiravir might improve the prognosis for critically ill COVID-19 pneumonia with COPD without negative influence on viral clearance or antibody production.

58-year-old man with fever and progressive dyspnea was admitted to the Showa University 4

Hospital, and showed severe respiratory failure which needed mechanical ventilation. His 5 chest computed tomography scanning showed emphysema and bilateral ground-glass 6 opacity caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. 7

He received 30 mg prednisolone for five days with antiviral drug of favipiravir, and was 8 successfully extubated on day five. A SARS-CoV-2 polymerase chain reaction (PCR) test 9 became negative on day 15. He was discharged on day 21. Serum IgM and IgG antibodies 10 against SARS-CoV-2 converted to positive on day 7 and they kept positive on day 54 for 11 both IgM and IgG. Combination treatment of short-course systemic corticosteroid and 12 favipiravir might improve the prognosis for critically ill COVID-19 pneumonia with COPD 13 without negative influence on viral clearance or antibody production. A chest X-ray revealed decreased lung permeability due to bilateral lung field 83 consolidation and ground-glass shadows, and chest computed tomography (CT) scanning 84 also showed bilateral ground-glass opacity with significant emphysematous changes in the 85 bilateral apex of the lung, and bilateral pleural effusion ( Fig. 1a and 1c) . SpO 2 was 84% even 86 when oxygen was administered at 12 L/min using a non-rebreather mask. Endotracheal 87 intubation was performed immediately as the patient was transferred to the intensive care 88 unit (ICU) to receive ventilator management. 89

As empiric therapy for severe pneumonia, tazobactam piperacillin (4.5 g × 3/day) was 90 infused intravenously, and azithromycin (500 mg/day) was administered via nasogastric 91 tube for three days. As there was a tendency for CO 2 retention in his arterial blood gas, we 92 diagnosed him as COPD exacerbation and 30 mg/day of prednisolone was administered for 93 five days to control COPD exacerbation. On day four of hospitalization, a polymerase chain 94 reaction (PCR) assay of SARS-CoV-2 obtained via nasal swab was found to be positive, 95 and the patient was diagnosed with COVID-19 pneumonia. Oral administration of favipiravir 96 was started on the same day. On the first day of treatment, 1800 mg/body were 97 administered every 12 hours, and from the second day, 800 mg/body were administered 98 D-dimer tended to increase after admission, thus the patient began receiving continuous 100 intravenous heparin infusions. On day five of hospitalization, the patient's respiratory 101 condition was improved, and the ventilatory support was discontinued. On day 10 of 102 hospitalization, as his symptoms and chest X-ray findings improved, the treatment of 103 antibiotics were discontinued. A contrast-enhanced CT scan performed on day 13 of 104 hospitalization revealed the presence of thrombosis in the right pulmonary artery, and from 105 the left common iliac vein to the femoral vein, which were diagnosed as a pulmonary 106 embolism and deep vein thrombosis, respectively. The continuous infusion of heparin was 107 changed to oral edoxaban of 60 mg/day. In addition, as WBC tended to decrease to 3400/µL 108 (neutrophils 60%, lymphocytes 29.1%), administration of favipiravir was terminated on day 109 13 (total administration of 10 days). On day 15 of hospitalization, a SARS-CoV-2 PCR test of 110 a nasal swab sample became negative. Oxygen administration terminated on day 19 of 111 hospitalization. Chest radiological and CT images were improved (Figure 1b and 1d) , and 112 the patient was discharged on day 21. His blood seropositivity for SARS-CoV-2 antibodies 113 was retrospectively analyzed using GenBody COVID-19 IgM/IgG kit (GenBody Inc., As limitations, this is a case report, and an objective clinical trial is necessary to evaluate 204

The authors would like to express their deep appreciation to Dr. Toru Kotani, and doctors 224 and ward staff in the intensive care unit of Showa University Hospital for their assistance 225 and care of this patient. 226

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Clinical Course and Outcomes of 344 Intensive Care Patients with COVID-19

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COVID-19) infection: a 281 systematic review and meta-analysis

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Epidemiologic Features and Clinical Course 296 of Patients Infected With SARS-CoV-2 in Singapore