Histomorphological Spectrum of Lung Lesions at Autopsy-A Tertiary Care Centre Experience

Background and aims: A wide variety of pathological conditions involve the lungs. In autopsy, the lungs are examined for disease, injury and other findings suggesting cause of death or related changes.Aims & Objectives: The present study aimed to study the histomorphological spectrum of lung lesions at autopsy and to assess the frequency of different types of lesions;and to associate histomorphological changes with cause of death.Material and Methods: It was a one-year observational study conducted in the Department of Pathology, Govt. Medical College, Jammu. Lung tissue pieces from all medicolegal autopsies received were fixed, examined grossly, processed;paraffin embedded sections obtained were stained with Hematoxylin and Eosin stain and examined under microscope. Findings were recorded and tabulated. Result(s): Out of 264 cases, males were predominantly affected (84%);median age was 38 years. The various changes observed were congestion (68%), edema (45.4%), pneumonia (5%), granulomatous inflammation (3%), diffuse alveolar damage (1.5%), haemorrhage (14.4%), interstitial changes (60%), malaria (0.4%) and malignancy (0.4%). Natural deaths were the commonest cause (75, 28%) followed by asphyxial deaths (65, 24.6%). Conclusion(s): Histopathological examination of lung autopsies highlights many incidental findings, establishes underlying cause of death, serves as a learning tool and also holds scope for detection of newer diseases.Copyright © 2023 JK Science.

Hafnia, a case of translocated septicemia

Case Report: Hafnia alvei, a member of the Enterococcus family, is a gram-negative anaerobe native to the gastrointestinal tract. While very rarely pathogenic, it has historically been associated with gastroenteritis, meningitis, bacteremia, pneumonia, and nosocomial wound infections. Here we report a non-fatal case of Hafnia-septicemia following recent ERCP for Choledocholithiasis. Case Report: 73-year-old Caucasian male with Chronic obstructive pulmonary disease, chronic kidney disease Stage 5, diabetes mellitus and hypertension who presented to the Emergency Department (ED) with a chief complaint of chills and fevers as well as worsening dry hacking cough and intermittent shortness of breath. Of note, patient had presented to the ED the previous day with abdominal pain and nausea after undergoing ERCP for Choledocholithiasis from day prior. Computed tomography (CT) imaging from 1st ED visit showed no acute signs of pancreatitis, however patient was noted to have bibasilar opacities. Lipase was normal at 39. Other lab work was significant for leukocytosis to 11 000. Patient's abdominal pain and nausea resolved while in the ED, he also denied shortness of breath and was breathing comfortably on room air. He was discharged from the ED with 7-day course of Azithromycin for community acquired pneumonia. On return visit next day, patient reported new onset shortness of breath and fevers. Physical exam was remarkable for hypoxia requiring 2 liters nasal cannula, and tachycardia to 104. Patient tested negative for Covid -19. Patient admitted for acute hypoxic respiratory failure and sepsis secondary to presumed bacterial pneumonia. Patient was started on IV Vancomycin and Cefepime and required oxygen support for hypoxia. He showed marked improvement by day two of hospitalization and was weaned off oxygen. Admission Blood cultures were positive for gram negative rods after 24 hours and subsequently grew Hafnia that was pan sensitive except to Ampicillin + Sulbactam. Repeat blood cultureswere negative 24 hours later. Patient was deemed medically stable on day 3 of admission and discharged on PO Levofloxacin for 10-day course for Hafnia septicemia and pneumonia. Discussion(s): When considering the etiology of septicemia especially in the context of a recent gastrointestinal procedure, translocation of anaerobic bacteria should be on the differential. Hafnia alvei is a rare pathologic cause of septicemia with only a handful of reported cases upon literature review. Copyright © 2023 Southern Society for Clinical Investigation.

Histophilus somni disease conditions with simultaneous infections by ovine gammaherpesvirus 2 in cattle herds from Southern Brazil.

This report investigated the cause of cattle mortality in two farms in Southern Brazil. The tissues of one animal from each farm (animals #1 and #2) respectively were used in pathological and molecular investigations to determine the possible cause of death. The principal pathological findings observed in animal #1 were pulmonary, myocardial, and encephalitic hemorrhages with vasculitis, and lymphoplasmacytic interstitial pneumonia with proliferative vascular lesions (PVL). The main pathological findings observed in animal #2 were purulent bronchopneumonia, hemorrhagic myocarditis, and lymphoplasmacytic interstitial pneumonia with PVL. An immunohistochemical assay detected intralesional antigens of a malignant catarrhal fever virus (MCFV) from multiple tissues of animal #2 while PCR confirmed that the MCFV amplified was ovine gammaherpesvirus 2 (OvGHV2), genus Macavirus, subfamily Gammaherpesvirinae; OvGHV2 was also amplified from multiple tissues of animal #1. Furthermore, PCR assays amplified Histophilus somni DNA from multiple fragments of both animals. However, the nucleic acids of Mannheimia haemolytica, Pasteurella multocida, Mycoplasma bovis, bovine respiratory syncytial virus, bovine alphaherpesvirus virus 1 and 5, bovine coronavirus, and bovine parainfluenza virus 3 were not amplified from any of the tissues analyzed, suggesting that these pathogens did not participate in the development of the lesions herein described. These findings demonstrated that both animals were concomitantly infected by H. somni and OvGHV2 and developed the septicemic and encephalitic manifestations of H. somni. Furthermore, the interstitial pneumonia observed in cow #2 was more likely associated with infection by OvGHV2.

IMPORTANCE OF STEROIDS: A CASE OF SPONTANEOUS BILATERAL ADRENAL HEMORRHAGE DUE TO THROMBOCYTOPENIA IN A PATIENT WITH MYELODYSPLASTIC SYNDROME

SESSION TITLE: Emergency Endocrine Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Spontaneous bilateral adrenal hemorrhage (BAH) resulting in adrenal crisis is a rare, but serious condition that can easily be missed as patients may present with non-specific symptoms (weakness, fatigue, nausea, vomiting, dizziness). It can escalate to hemodynamic instability in the setting of adrenal crisis. The most common cause is meningococcal disease, other causes include trauma, septicemia, and coagulopathies. Without treatment it is fatal and carries a high mortality rate of 15%;Waterhouse-Friderichsen syndrome has been reported with 55-60% mortality. Here, we describe a case of a patient with a history of myelodysplastic syndrome (MDS) who presented with multiple readmissions with a septic shock picture with unknown source of infection and was finally diagnosed with bilateral adrenal hemorrhage causing adrenal crisis. CASE PRESENTATION: An 85-year old independently living man with past medical history of MDS and hypertension presented after a syncopal episode at home with altered mental status. Treatment was initiated for a urinary tract infection which progressed to shock. His labs were notable for leukocytosis in the 40,000s and a platelet count in the 30s. He was found to have BAH on imaging. He was started on broad-spectrum antibiotics, vasopressors and stress-dose steroids with improvement in his condition and eventually discharged home. He was readmitted to the ICU twice within a month for shock, each time with a negative infection workup, as he had been discharged home without steroids to follow up with an endocrinologist. After his third readmission, he was discharged on steroids and he did not have any further readmissions to the hospital. Exhaustive investigations were made into possible infectious causes of his BAH as well as possible vasculitis and hematologic causes. It was determined to likely be in the setting of thrombocytopenia brought on by his MDS. DISCUSSION: Thrombocytopenia is a rare cause of BAH and adrenal crisis. Review of literature mostly describes cases of heparin-induced thrombocytopenia, a few cases of COVID19 and vaccine-induced immune thrombocytopenia after the COVID vaccine. In our patient, it was thought that MDS predisposed him to spontaneous BAH and subsequently adrenal crisis, which has only been described once before in the literature. Stress dose steroids are commonly used in the ICU for relative adrenal insufficiency. Due to the acuity of his condition and concern for relative adrenal insufficiency, our patient was tapered off steroids and discharged home with endocrinology follow up which led to his frequent readmissions as his underlying problem was not addressed. CONCLUSIONS: Adrenal insufficiency is rare and may be difficult to diagnose especially in the acute setting. It is important to recognize and treat adrenal crisis as it has a high mortality rate. MDS is a rare cause. Reference #1: Manganaro L, Al Ansari N, Barchetti F, et al. Bilateral Adrenal Hemorrhage in a Patient with Myelodysplastic Syndrome: Value of MRI in the Differential Diagnosis. Case Reports in Radiology. 2013;2013:e479836. doi:10.1155/2013/479836 Reference #2: Rosenberger LH, Smith PW, Sawyer RG, Hanks JB, Adams RB, Hedrick TL. Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia. Crit Care Med. 2011;39(4):833-838. doi:10.1097/CCM.0b013e318206d0eb Reference #3: Fatima Z, Tariq U, Khan A, et al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018;10(6):e2830. Published 2018 Jun 18. doi:10.7759/cureus.2830 DISCLOSURES: No relevant relationships by Robbert Crusio No relevant relationships by Justyna Michalik No relevant relationships by Aditya Saholi

SEPTIC SHOCK SECONDARY TO FUSOBACTERIUM NECROPHORUM LIVER ABSCESSES AND QUESTIONABLE RELATIONSHIP WITH COVID-19 INFECTION IN A HEALTHY YOUNG FEMALE

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Fusobacterium (FB) are anaerobic, Gram-negative bacilli found in the normal flora of the oral, gastrointestinal, vaginal and upper respiratory tract mucosa. It can cause soft tissue infections and rarely causes bacteremia, yet Fusobacterium bacteremia is associated with high rate of ICU admission, extended hospitalization and significant mortality. Pyogenic liver abscess is a rare indolent disease and is mostly secondary to bacterial infection. CASE PRESENTATION: A 39-year-old female with no comorbidities presented with nausea, vomiting, fatigue, diarrhea, fatigue, heavy menstrual bleed, and high-grade fever. Symptoms started four days before the presentation. She reported a positive COVID-test two weeks earlier and a new IUD placement five weeks before presentation. She is sexually active with one male partner and does not use a contact barrier. On presentation, she was hypotensive, tachycardic, ill-looking with rapid shallow breathing, and fever of 100.7. EKG showed sinus tachycardia, CXR showed no pulmonary disease. Blood tests were significant for leukocytosis, elevated serum lactic acid, and elevated D-dimer. CTA chest was remarkable for two 2x3 cm liver cysts. Patient was admitted to the MICU and started on IV fluids Boluses, Norepinephrine drip, Ceftriaxone and Azithromycin. Gynecology was consulted and recommended against removing the IUD as patient had no signs of IUD infection. Patient continued to be critically sick. Gynecology team was recontacted and removed the IUD and was uninfected on culture. Antibiotics were switched to Vancomycin and Piperacillin-Tazobactam. MRI liver with contrast confirmed the diagnosis liver abscess. Patient received bedside US-guided aspiration, it was remarkable for 16 cc of frank pus. Patient showed significant improvement after procedure and was transferred to the medical floor within 24 hours. Blood culture grew F. Necrophorum and antibiotics were switched to Clindamycin. DISCUSSION: FB is part of the vaginal flora. Mucosal disruption during IUD placement can precipitate disseminated infection with liver abscesses and/or sepsis. Absence of signs of GU tract infection or a non-infective IUD doesn't rule out FB sepsis. Patient Presented five weeks after IUD placement which fits the indolent nature of pyogenic liver abscess. Four cases of F. Nucleatum bacteremia were reported recently in Belgium in COVID patients. One of the cases was healthy young female. Our similar scenario raises a question about a potential association between COVID and risk of floral septicemia. Our patient has F. necrophorum. CONCLUSIONS: Patient presenting with sepsis and liver cyst should be evaluated for liver abscess as appropriate. Recent procedures and mucosal instrumentation can precipitate liver abscess and should be considered if the timing suggest an indolent course. Further studies are needed to evaluate a potential link between COVID infection and FB bacteremia. Reference #1: Goldberg EA, Venkat-Ramani T, Hewit M, Bonilla HF. Epidemiology and clinical outcomes of patients with Fusobacterium bacteraemia. Epidemiol Infect. 2013 Feb;141(2):325-9. doi: 10.1017/S0950268812000660. Epub 2012 Apr 17. PMID: 22717143. Reference #2: Garcia-Carretero R. Bacteraemia and multiple liver abscesses due to Fusobacterium nucleatum in a patient with oropharyngeal malignancy. BMJ Case Rep. 2019 Jan 29;12(1):e228237. doi: 10.1136/bcr-2018-228237. PMID: 30700472;PMCID: PMC6352811. Reference #3: Wolff L, Martiny D, Deyi VYM, Maillart E, Clevenbergh P, Dauby N. COVID-19-Associated Fusobacterium nucleatum Bacteremia, Belgium. Emerg Infect Dis. 2021 Mar;27(3):975-977. doi: 10.3201/eid2703.202284. Epub 2020 Dec 8. PMID: 33292922;PMCID: PMC7920680. DISCLOSURES: No relevant relationships by Zainab Abdulsada No relevant relationships by Ahmed Abomhya No relevant relationships by Richard Fremont

Endogenous panophthalmitis in a patient with COVID-19 during hospitalization in an intensive care unit: A case report.

Purpose: To report a case of endogenous panophthalmitis in a patient with COVID-19 during treatment in an Intensive Care Unit. Observation: A 64-year-old woman with COVID-19 and Salmonella septicemia presented with decreased visual acuity, ocular pain, and proptosis in her right eye after treatment with favipiravir, intravenous dexamethasone, and ceftriaxone. An ocular examination of her right eye revealed periorbital tenderness, exophthalmos, and corneal haze. The ultrasonography showed a subretinal abscess. Her right eye lost light perception vision and underwent enucleation. Microbiologic evaluation of the enucleated right eye was negative for organisms. Conclusions and importance: Patents with COVID-19 may develop severe ocular involvement after COVID-19 due to a generalized reduction in immunity. Comorbidities and intensive care unit treatments can predispose COVID-19 patients to endogenous panophthalmitis.

Clinical Presentation of Melioidosis: A Case Series

Introduction: Melioidosis is an infectious disease caused by Gramnegative bacterium Burkholderia pseudomallei. It is a potentially fatal disease endemic to tropical and subtropical regions. Bacteria spread by contact with contaminated water and soil. The presentation of this disease is variable ranging from localized infection to fulminant septicemia and multi-organ dysfunction. Objective: The purpose of this study is to look into clinical presentation, treatment, and outcomes of confirmed melioidosis cases in a tertiary care hospital. Materials and methods: This is a retrospective case series of patients in a single tertiary care center between January 2018 and September 2021. We present a series of 19 cases admitted with a confirmed diagnosis of melioidosis. Three of 19 cases discontinued treatment in between but were included in the analysis. Results: We report 19 cases of melioidosis admitted to our hospital in a span of 3 years (17 males and 2 females). The median age of presentation was 47 years. The disease had varied presentation with lung involvement in 11 cases (57%), solid organ abscesses in 8 cases (42%), osteomyelitis and septic arthritis in 5 (26%), and acute pyelonephritis in 2 cases (10%). Lung involvement was seen as consolidation, septic emboli, and solid nodular lesions. Most common risk factor associated with disseminated disease was diabetes. Diabetes was seen in 17 cases (89.4%). All patients had uncontrolled blood sugars and 2 cases presented in DKA. Other comorbidities seen were systemic hypertension (16%), coronary artery disease (10%), chronic liver disease (10%), post COVID (10%), and SLE (5%). ARDS complicating lung condition was seen in 6 patients (54%) of which 3 patients were managed with NIV and 3 patients required invasive mechanical ventilation. AKI was seen in 11 patients (57.8%) of which 8 patients recovered from AKI and 3 patients required renal replacement therapy. One patient with associated lupus nephritis required long-term hemodialysis. Altered liver function test was seen in 11 patients (57.8%). Bone marrow suppression is common. Three patients had pancytopenia and 10 patients had thrombocytopenia. Hyponatremia was the most common electrolyte abnormality seen in 7 patients (36.8%). Of the 19 cases admitted three patients did not continue treatment. Median hospital stay for the remaining 16 cases was 16 days. 15 out of 16 cases survived with a survival rate of 93.7% and one mortality (6.2%). Conclusion: Melioidosis is a potentially fatal disease. High index of suspicion is required for diagnosing this condition due to its varied presentation. Early diagnosis and appropriate treatment is the cornerstone in improving the outcome. Though mortality was less than 6%, they have significant morbidity with prolonged ICU and hospital stay leading to increased economic burden.

Social characterization of COVID-19 in the state of Amazonas, Brazil

Objectives: To compare the number of deaths that occurred in the state of Amazonas and in Brazil, from March 16th to August 20th 2020, using the variables skin color, sex, place of death, age group and association with COVID-19, and secondly, to verify whether between 2019 and 2020, in the period from March 16th to August 20th, there was a significant change in the number of deaths from diseases not associated with COVID-19. Methods: We searched the databases of the Brazilian public agency "Transparency Portal" for the data on deaths that occurred in the state of Amazonas and Brazil in the period from March 16th to August 20th, 2019 and 2020. The absolute frequencies and percentages of the variables studied were used for statistical analysis. Results: COVID-19 was responsible for an 11.01% increase in deaths in Brazil;however, this rate quadrupled in the state of Amazonas. In relation to age group, there was a similar percentage between Amazonas and the national average. The stratified analysis showed significant differences between genders and races, with higher death rates in men and people of brown/black skin. The number of deaths at home increased significantly, especially those from causes not associated with COVID-19. Conclusions: The national drop in deaths from diseases not associated with COVID between March and August 2020 in Brazil is misleading and may be due to the result of misreported causes of death.

Severity level and ventilation procedures in COVID-19 patients in a semi-intensive care unit

Introduction and Purpose of the study: SARS-CoV2 infection is characterized by massive involvement of the respiratory system. During the various waves, the patients admitted to the Covid wards presented different degrees of pulmonary involvement and numerous comorbidities. Administration of oxygen therapy was the prevalent measure in almost all subjects. The aim of our study was to verify the level of severity and ventilation procedures in a group of subjects hospitalized for SARS-CoV2 infection. Materials and Methods: 388 subjects admitted to the semi-intensive Covid Unit of the F. Miulli Hospital in 2020 were retrospectively analyzed, by examining the SDOs. The main diagnoses and procedures performed were identified. A severity cluster was identified characterized by death, ventilation and hospitalization in the semi-intensive area (cut off at 14 days). Results: 82 were the deceased (21.1%). The main diagnoses most represented were: 84.2% respiratory failure, 3.3% heart failure, 2.5% pulmonary embolism and 1.5% septicemia. Regarding the procedures, 31.9% underwent C-PAP ventilation, while 0.7% underwent non-invasive mechanical ventilation. 64% of the subjects had a severe degree of disease evidenced by the composite cluster of deaths, ventilation and at least 14 nights in semi-intensive care. Conclusions: Our data shows that in the face of almost all patients with respiratory failure, about one third underwent ventilation procedures (C-PAP and NIV). More than half of the subjects had a severe degree of disease.

Co-morbidities and Complications in COVID-19 Recovered Patients in Bhilwara District, Rajasthan, India: A Descriptive Study

Introduction: Coronavirus Disease-19 (COVID-19) infection is associated with high rates of pulmonary and extrapulmonary complications that may continue to incur morbidity, disability and delayed mortality in survivors. These include hyperglycaemia, cardiac injury, acute ischaemic or haemorrhagic stroke, neurological deficits, acute kidney injury and liver injury. Aim: To describe symptoms and complications being faced by COVID-19 recovered patients, as well their socio-demographic profile and co-morbidities. Materials and Methods: This was a cross-sectional descriptive study conducted for the period of 12 months from April 2020-March 2021. Out of nearly 10,000 recovered COVID-19 patients, 1000 (calculated sample size) patients were selected randomly. The patients were categorised gender-wise (male and female) and locality-wise (urban and rural) and an attempt was made to find if any significant difference exists in the symptoms and complications based on above categorisation. The test used for this purpose was Chi-square test and Fisher’s-exact test. Results: Mean age of participants was 50.2±15.7 years and 43.8% had co-morbidities. Common complications included hyperglycaemia (n=28), acute kidney injury (n=8), acute liver injury (n=5), cardio-vascular accident and stroke (n=5), septicaemia (n=8), ischaemic heart disease (n=7), deep vein thrombosis (n=2), cytokine release syndrome (n=10) and post COVID-19 fibrosis (n=3). For septicaemia, a statistically significant difference (p<0.001) was found between urban and rural areas whereas no significant difference in post COVID-19 complications between males and females was observed. conclusion: The most common co-morbidity was diabetes mellitus and most common complication reported was hyperglycaemia.

Melioidosis: A Neglected Infection in Bangladesh

Bangladesh is an example of a highly populous, agricultural country where melioidosis may be a significantly under diagnosed cause of infection and death. A recent regression model predicted 16,931 cases annually in Bangladesh with a mortality rate of 56%. However, we only manage to confirm (culture) around 80 cases in last 60 years. A lack of awareness among microbiologists and clinicians and a lack of diagnostic microbiology infrastructure are factors that are likely to lead to the underreporting of melioidosis. Melioidosis transmits through inoculation, inhalation and ingestion. Diabetes mellitus is the most common risk factor (12 times higher chance of getting the infection) predisposing individuals to melioidosis and is present in >50% of all patients. The clinical presentation is widely varied and can be mistaken for other diseases such as tuberculosis or more common forms of pneumonia giving rise to its nickname as the “great mimicker”. Disease manifestations vary from pneumonia or localized abscess to acute septicemias, or may present as a chronic infection. Culture is considered the current gold-standard for diagnosis and culture-confirmation should always be sought in patients where disease is suspected. It is strongly recommended that any non–Pseudomonas aeruginosa, oxidase-positive, Gram-negative bacillus isolated from any clinical specimen from a patient in an endemic area should be suspected to be Burkholderia pseudomallei (BP). In addition, based on antibiogram, any Gramnegative bacilli that are oxidase-positive, typically resistant to aminoglycosides (e.g., gentamicin), colistin, and polymyxin but sensitive to amoxicillin/clavulanic acid should be considered as BP. This bacteria is inherently resistant to penicillin, ampicillin, first generation and second-generation cephalosporins, gentamicin, tobramycin, streptomycin, and polymyxin. For intensive phase (10 to 14 days), ceftazidime or carbapenem is the drug of choice. For eradication phase (3 to 6 months), oral trimethoprim/ sulfamethoxazole is the drug of choice. Surgery (drainage of abscess) has an important role in the management of melioidosis. Preventive measures through protective gears could be useful particularly for the risk groups.

Case Report: Interferon- γ Rescues Monocytic Human Leukocyte Antigen Receptor (mHLA-DR) Function in a COVID-19 Patient With ARDS and Superinfection With Multiple MDR 4MRGN Bacterial Strains.

Background: CD14+ monocytes present antigens to adaptive immune cells via monocytic human leukocyte antigen receptor (mHLA-DR), which is described as an immunological synapse. Reduced levels of mHLA-DR can display an acquired immune defect, which is often found in sepsis and predisposes for secondary infections and fatal outcomes. Monocytic HLA-DR expression is reliably induced by interferon- γ (IFNγ) therapy. Case Report: We report a case of multidrug-resistant superinfected COVID-19 acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support. The resistance profiles of the detected Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii and Citrobacter freundii isolates were equipped with resistance to all four antibiotic classes including carbapenems (4MRGN) and Cefiderocol in the case of K. pneumoniae. A causal therapeutic antibiotic strategy was not available. Therefore, we measured the immune status of the patient aiming to identify a potential acquired immune deficiency. Monocyte HLA-DR expression identified by FACS analysis revealed an expression level of 34% positive monocytes and suggested severe immunosuppression. We indicated IFNγ therapy, which resulted in a rapid increase in mHLA-DR expression (96%), rapid resolution of invasive bloodstream infection, and discharge from the hospital on day 70. Discussion: Superinfection is a dangerous complication of COVID-19 pneumonia, and sepsis-induced immunosuppression is a risk factor for it. Immunosuppression is expressed by a disturbed antigen presentation of monocytes to cells of the adaptive immune system. The case presented here is remarkable as no validated antibiotic regimen existed against the detected bacterial pathogens causing bloodstream infection and severe pneumonia in a patient suffering from COVID-19 ARDS. Possible restoration of the patient's own immunity by IFNγ was a plausible option to boost the patient's immune system, eliminate the identified 4MRGNs, and allow for lung recovery. This led to the conclusion that immune status monitoring is useful in complicated COVID-19-ARDS and that concomitant IFNγ therapy may support antibiotic strategies. Conclusion: After a compromised immune system has been detected by suppressed mHLA-DR levels, the immune system can be safely reactivated by IFNγ.