ABSTRACT
SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: We discuss a case of successful use of alteplase and dornase per MIST II protocol for the management of a loculated pleural effusion secondary to COVID-19 pneumonia. CASE PRESENTATION: 52 year old male was initially admitted for MRSA bacteremia and began appropriate antibiotic therapy. His chest radiograph on presentation was unremarkable. Seven days into his hospital course he tested positive for COVID-19 pneumonia, and developed increasing shortness of breath and escalating oxygen requirements. At this time he had a large loculated left sided pleural effusion on chest computed tomography. A pigtail catheter was placed with removal of 600ml of cloudy yellowish fluid. Follow-up CXR showed slight interval improvement, however a large loculated effusion remained. Pleural fluid studies was exudative, lymphocytic predominant (78%) with elevated pleural fluid lactate dehydrogenase of 786 U/L, pH 8.0, and glucose 97mg/dl. Additional pleural fluid workup was unremarkable, including negative cultures, AFB staining, and benign cytology. After other known causes of lymphocyte predominant pleural effusion were ruled out, and following review of the current medical literature, the conclusion was made that his effusion was most likely related to COVID-19. The decision was made to attempt lysis of the loculations with alteplase and dornase per MIST II protocol. This resulted in significant chest tube output (totaling 3480ml additional output over the ensuing days) as well as marked improvement in chest imaging. The protocol was continued for 3 days which the patient tolerated well overall. DISCUSSION: COVID-19 related pleural effusions occur with an incidence of about 7.3% of cases with an overall lag time of 11 days from symptom onset. Based on observational studies, these pleural effusions are unilateral in 66.8% of cases with a lymphocyte or neutrophilic predominance and significantly elevated pleural fluid to serum LDH ratio. The differential for exudative lymphocyte predominant pleural effusions with elevated LDH include malignancy, rheumatoid effusion, tuberculosis, and viral infections. The pleural studies workup was unremarkable for these conditions. The MIST-2 protocol was followed per the original study, with instillation of tPA 10mg via pigtail catheter which was clamped for 1 hour, opened to drain for 1 hour, then repeated with dornase 5mg. To the best of our knowledge, this is the first documented case of using MIST 2 protocol for a loculated pleural effusion related to COVID-19. CONCLUSIONS: COVID-19 related loculated pleural effusion is an infrequent occurrence that present as lymphocyte predominant exudative that can loculate with elevated lactate dehydrogenase. This is the first case of using alteplase and dornase for its management and we have demonstrated that it can be both a safe and effective method. Additional prospective studies are needed to further investigate this method. Reference #1: Chong WH, Saha BK, Conuel E, Chopra A. The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review. Heart Lung. 2021;50(4):481-490. doi:10.1016/j.hrtlng.2021.02.015 Reference #2: Ahmadinejad Z, Salahshour F, Dadras O, Rezaei H, SeyedAlinaghi S. Pleural Effusion as a Sign of Coronavirus Disease 2019 (COVID-19) Pneumonia: A Case Report. Infect Disord Drug Targets. 2021;21(3):468-472. doi: 10.2174/1871526520666200609125045. PMID: 32516107. Reference #3: Rahman, N, et al. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. N Engl J Med 2011;365:518-526. DOI: 10.1056/NEJMoa1012740 DISCLOSURES: No relevant relationships by Zachary Chandler No relevant relationships by James Cury No relevant relationships by Peter Staiano No relevant relationships by Daniel Weigle