key: cord-1042386-bhbkkwjx
authors: Galindo, Javier L.; Galeano, Adriana C.
title: Should a Nonresolving Pneumonia Be Treated as an Organizing Pneumonia in Times of COVID-19?
date: 2021-03-30
journal: Ann Am Thorac Soc
DOI: 10.1513/annalsats.202103-317le
sha: 46e582a2ecf868fbe1229cba0e5fd045e30a17ff
doc_id: 1042386
cord_uid: bhbkkwjx

nan

We read with interest the article entitled "Persistent Post-COVID-19 Interstitial Lung Disease: An Observational Study of Corticosteroid Treatment" (1). The authors described 325 patients with coronavirus disease (COVID-19) who remained symptomatic at 6 weeks after discharge from the hospital. Although lung biopsies were not performed, the multidisciplinary team meeting diagnosed in 35 patients an organizing pneumonia-like pattern according to radiological findings. Thirty patients were offered treatment with corticosteroids with a rapid wean over 3 weeks, resulting in functional, radiological, and symptomatic improvement; however, three patients who did not receive corticosteroids had a degree of improvement as well. The findings of the study suggest that organizing pneumonia induced by COVID-19 could be a therapeutic goal in some patients with nonresolving pneumonia, but the challenge for clinicians has to do with who, when, and how these patients should be treated.

Previous series have described clinical improvement of patients with nonresolving COVID-19 pneumonia after a prolonged course of corticosteroids, some of them with organizing pneumonia corroborated by transbronchial biopsies (2) (3) (4) . Autopsy reports have reported findings of acute fibrinoid organizing pneumonia supporting the benefit of corticosteroid therapy (5) . Nonetheless, because the histopathological study is not the rule in COVID-19, the true frequency of organizing pneumonia and its course in this context are unknown; we cannot tell when these findings are part of a slow recovery that requires treatment or a watch-and-wait approach, as it certainly happened with the three patients in the study that did not receive corticosteroids. Patients with COVID-19 pneumonia, especially those who required intensive care unit management, are prone to have residual clinical, imaging, and histological abnormalities for months that are not necessarily irreversible (6) .

The authors did an extensive multidisciplinary evaluation and referred the patients enrolled to rehabilitation services; we would like to highlight some relevant points about the approach to nonresolving pneumonia in COVID-19. What is defined as nonresolving or slowly resolving pneumonia is arbitrary, but it often describes the clinical scenario in which symptoms, signs, or radiological opacities have a course that is not what is expected despite an appropriate treatment. The scenario of persistent symptoms in COVID-19 should always lead to evaluate differential diagnoses that may delay the clinical recovery, such as bacterial superinfection, left heart failure, pulmonary embolism, and physical deconditioning, or associated complications such as organizing pneumonia and pneumothorax. The role of histological study to confirm organizing pneumonia has not been addressed, but its benefit must be weighted according to the limited evidence to date and the risk of performing lung biopsies, particularly in patients undergoing mechanical ventilation. Individualization of each case of nonresolving pneumonia could help to plan a multidimensional and tailored intervention of the causes of persistent symptoms.

High-uncertainty clinical scenarios in which physicians could be tempted to indicate unproven strategies or with scarce medical evidence, especially in the overwhelmed context of a pandemic, can be risky and not necessarily effective for everyone. We do believe that the study by Myall and colleagues helps to promote the design of clinical trials to address the potential benefit and safety of the prolonged use of corticosteroids or the watch-and-wait strategy in patients with persistent symptoms and suspected organizing pneumonia owing to COVID-19.

Persistent post-COVID-19 interstitial lung disease: an observational study of corticosteroid treatment

Severe organising pneumonia following COVID-19

Organizing pneumonia and COVID-19: a report of two cases

Organizing pneumonia: a late phase complication of COVID-19 responding dramatically to corticosteroids

A systematic review of pathological findings in COVID-19: a pathophysiological timeline and possible mechanisms of disease progression

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study