key: cord-1040102-l6a2t2uq
authors: Hassan, Mohamed Eliwa; Hasan, Hasan MSN.; Sridharan, Kannan; Elkday, Adel; ElSeirafi, Mohamed MA.
title: Dexamethasone in severe COVID-19 infection: A case series
date: 2020-08-28
journal: Respir Med Case Rep
DOI: 10.1016/j.rmcr.2020.101205
sha: f915da6407c28e150785c85f427949b98cc76d77
doc_id: 1040102
cord_uid: l6a2t2uq

Evidence supporting the use of dexamethasone in severe COVID-19 patients is emerging. In this case series, we share our experience in using dexamethasone in five COVID-19 infected patients with acute respiratory distress syndrome.

Dexamethasone, a synthetic potent long-acting broad-spectrum corticosteroid, has been recently debated to reduce mortality in severely ill COVID-19 infections. [1] The protective role of dexamethasone is primarily related to its anti-inflammatory properties that contain the cytokine storm related worsening of the disease. [2] Fifteen to 30 percent of patients with COVID-19 infections present with severe illness resulting in acute respiratory distress syndrome (ARDS) that is associated with mortality of around 65%. [3] Dexamethasone use in ARDS patients has shown to reduce the risk of mortality with the age-adjusted risk ratio of 0.83 [95% confidence intervals: 0.74-0.92]. [4] Several clinical trials evaluating the role of dexamethasone in severe COVID-19 patients are ongoing. [5, 6] World Health Organization has even urged to scale-up the production of dexamethasone by pharmaceutical industries as the demand is likely to increase.

[7] In light of the emerging role, we wish to share our experience in using dexamethasone in severe COVID-19 patients with acute respiratory distress syndrome.

A 38-year-old woman, a known case of Down syndrome was admitted on 28/5/2020 with COVID-19 pneumonia. She deteriorated and was transferred to intensive care unit (ICU) on 12/6/2020 due to type 1 respiratory failure. Her acute lung injury score was 2.5 and she was diagnosed with moderate-to-severe lung injury. She was J o u r n a l P r e -p r o o f Page 4 of 12 mechanically ventilated and she was commenced lopinavir/ritonavir, ribavirin, meropenem, low-molecular weight heparin, linezolid and doxycycline on the same day. She did not meet the criteria for receiving tocilizumab and there was no availability of convalescent plasma that was compatible for the patient. Intravenous dexamethasone 6 mg once daily was initiated on 18/6/2020. The patient improved gradually and she was extubated on 22/6/2020 and was put on high-frequency nasal canula at 60%. Amongst the laboratory biomarkers, C-reactive protein (CRP) declined from 227.6 to 17.5 mg/L; D-dimer (DD) from 21.55 to 4.94 µg/ml; lactate dehydrogenase (LDH) from 577 to 486 U/L; interleukin-6 (IL-6) from 15.2 to 11.39 pg/ml; and total white blood cell (WBC) count from 13.14 to 8.62 x 10 9 /L. She was discharged from ICU on 27/6/2020.

A 44-year-old woman with co-morbid systemic hypertension and obesity was diagnosed with COVID-19 pneumonia with type 1 respiratory failure on 13/6/2020. Her arterial oxygen saturation was 84% with the acute lung injury score of 3 and she was diagnosed with ARDS. She was initiated on high-flow nasal canula at 80% and was commenced on lopinavir/ritonavir, ribavirin and interferon-β immediately.

Convalescent plasma therapy was provided on 16/6/2020. Her oxygen saturation DD from 6.7 to 4.3 µg/ml; and IL-6 from 16.13 to 3.56 pg/ml. She improved in 5 days and was discharged from ICU on 27/6/2020.

An 85-year-old woman with co-morbid systemic hypertension, hyperlipidemia and hypothyroidism was diagnosed with COVID-19 pneumonia on 21/6/2020. Her acute lung injury score was 2.5 and she was diagnosed with ARDS. She was started on lopinavir/ritonavir, interferon-β, linezolid and meropenem. Her oxygen saturation continued to deteriorate and she was kept on non-rebreather mask with 10 liters of oxygen. Computed tomography chest revealed bilateral pulmonary embolism and she was commenced on enoxaparin. The desaturation continued and she was moved to high frequency nasal canula with 100% 40 L/min oxygen on 26/6/2020 and stayed on this for two days. She was initiated injection dexamethasone 6 mg once daily intravenously on 26/6/2020 and on the same day she received two doses of https://www.who.int/dg/speeches/detail/who-director-general-s-openingremarks-at-the-media-briefing-on-covid-19---22-june-2020. 

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