High dose methylprednisolone in COVID-19 pneumonia with severe respiratory failure, a case series

Background: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). SARS-CoV-2 presents symptoms include fever, cough, dyspnoea, myalgia or fatigue. While most patients tend to have a mild illness, a minority of patients develop severe hypoxia, ARDS, requiring hospitalization and mechanical ventilation. The current management of COVID-19 is based generally on supportive therapy and prevention of respiratory failure. There are still no targeted therapeutic options available for SARS-CoV-2, and symptomatic management is the mainstay of treatment in ARDS associated with COVID-19. Case Report: We describe a case series of five patients with severe COVID-19-related pneumonia and respiratory failure who were successfully treated with intravenous short-term high-dose methylprednisolone. These patients improved clinically in about a week and shortly were able to stop oxygen therapy and to be discharged home. We also report a series of 5 patients chosen for confrontation, admitted to our department for severe COVID-19 related pneumonia and respiratory failure who were treated with dexamethasone instead of short-course high-dose methylprednisone. Conclusions: As reported above, after short-term intravenous highdose methylprednisone followed by oral methylprednisone, all the patients showed early clinical and radiological improvement. Finally methylprednisone offers a potential cost-effective therapeutical choice for developing countries and poor-resourced backgrounds.

Unusual back pain

Background: Often the onset symptoms of a disease don't easily direct towards the correct diagnosis. Furthermore, the CoViD-19 pandemic has often been an obstacle to obtaining a quick diagnosis. Description of the case: Male 49-year-old patient admitted to emergency room for persistent back pain, asthenia and weight loss. Physical examination revealed a palpable mass in the right gluteal region, chest X ray an enlargement of mediastinum. Nasopharingeal swab for CoViD-19 was positive (even if negative for CoViD-related symptoms);he was so hospitalized in our Internal Medicine CoViD Ward. Blood samples found microcytic anemia (thalassemic trait carrier);high ferritin (1072 ng/ml), aptoglobin (297 mg/dl, nv <200) and B2 microglobulin (3.25 mg/l, nv <2.53);K and L chains normal with K/L serum ratio reduction, increase in urine sample. Lymphocyte subpopulations were indicative of lymphopenia. Suspecting a lymphoproliferative disease, he performed a chest and abdomen CT scan that found: multiple bilateral pulmonary nodules, the largest one 10x9 cm in the left lung;a left renal lesion11x10 cm;a mass 9.5 cm of the sacroiliac left wing and splenomegaly (145 mm). We thus performed a US-assisted biopsy of the mass in the gluteal region. The histological examination allowed to identify metastasis from clear cell renal carcinoma. Conclusions: We report this case to highlight the peculiarity of onset of this renal carcinoma, in absence of genitourinary symptoms. Diagnostic autonomy can be a winning weapon in accelerating the diagnostic process, even more so in times of CoViD-19 pandemic.

Acute eosinophilic pneumonia: A rare disease

Background: Acute eosinophilic pneumonia (AEP) is a raredisease. Patients can develop hypoxemic respiratory failure andsometimes require mechanical ventilation.Case report: Woman 20 years old with frequent episodes ofhyperpyrexia and dry cough mostly nocturnal which improved withspray bronchodilators. The patient went to the pulmonologist whofound whistles, hisses and blood sputum. The spirometry showedpositive bronchodilatation. The Physician diagnosed asthma andprescribed steroid and bronchodilators. Because of symptomsworsening, the patient went to the hospital and she was admittedto our department. The chest ultrasound and x-ray showed diffusebilateral infiltrates and interstitial syndrome. Laboratory testsrevealed eosinophils 16500, IgE 7953 IU / ml, PCR slightlyincreased. We started with steroid, antibiotic and antifungaltherapy. On second day the symptoms and the laboratory testimprove. After one week the patient was discharged.Conclusions: Diagnosis of AEP is based on clinical criteria, ipere- osinophilia in the blood and at bronchoalveolar lavage, the exclusion of other causes of pulmonary eosinophilia. Lung biopsy israrely necessary. Differential diagnosis with cases detected inChina of coronarovirus infection (2019-nCoV) has recently beenvery interesting. Initial management includes supportive care, empiric antibiotics and systemic glucocorticoid therapy. If the patientdoes not respond to steroid or there is contraindication to its use,he could be treated with immunosuppressive or biological drugs.

Searching for find

Background: COVID19 pneumoniae presented, especially at thebeginning of pandemia, diagnostic difficulties dues to the frequentswabs negativity (in contrast with clinic and imaging) and the notwidespread availability or doubtful interpretation of serologicaltests. Clinical case: 52 years old man with cough and fever for a week,admitted to our Medical Ward for acute respiratory failure onMarch 24, 2020. Positive history of epidemiological contact, obesity and hypertension. Laboratory tests showed an increase in PCR,LDH and ferritin. EGA showed pO2 62%, pCO2 37% and P/F 298and oxygen therapy was started (Venturi mask 6 l/min). Chest Xray was positive for interstitial pneumonia. Lung ultrasound showeddiffuse B lines (especially in posteral basal fields) and irregularpleural line with small subpleural thickenings. Despite a first negative swab, we considered the patient affected by Covid19 pneumoniae and started therapy: hydroxychloroquine 600 mg die,azithromycin 500 mg die and fondaparinux 2.5 mg die for 7 dayswith rapid clinical improvement. Swab repeated after a week wasnegative but COVID19 search in sputum was doubtful two times.Diagnosis was definitely confirmed three weeks after discharge,when our laboratory was finally able to perform serological testsfor COVID 19 on blood samples collected at the admission. BothIgM and IgG were high titer positive.Conclusions: This case report highlights how COVID19 pneumoniae diagnosis needs combination of epidemiology, clinical manifestations, laboratory tests, imaging and how swab negativity can'texclude it.