BILATERAL PLEURAL EFFUSIONS WITHOUT SIGNIFICANT ASCITES IN AN OVARIAN HYPERSTIMULATION PATIENT RECOVERED FROM COVID-19: A CASE REPORT

ABSTRACT

OBJECTIVE: To describe a patient who developed severe ovarian hyperstimulation syndrome (OHSS) with uncharacteristic features after recent COVID-19 infection. MATERIALS AND METHODS: A patient with prior mild COVID-19 developed an atypical case of OHSS with significant bilateral pleural effusions requiring bilateral thoracentesis and only minimal abdominal ascites. Isolated pleural effusions without significant ascites in not frequently found in patients with OHSS, with only one case with an effusion requiring a thoracentesis in 771 patients in a 1995 Canadian study. COVID-19 is known to cause inflammatory responses in the lung, however, pleural effusions are a rare symptom and usually only in those with severe disease. Long-standing damage from COVID-19, or ''post-COVID conditions'' is still under active investigation but can occur in patients even with mild disease. RESULTS: A 25yo G0 (BMI 27, AMH 9) without significant past medical or surgical history underwent IVF due to male factor infertility and polycystic ovarian syndrome (PCOS). She was diagnosed with COVID-19 5 weeks prior to stimulation and reported a mild course not requiring hospitalization. She underwent a long agonist protocol with a peak E2 of 6700 on day of HCG trigger (5000u) and had 42 oocytes retrieved. On POD #3, she presented with abdominal pain with distension and shortness of breath. A therapeutic paracentesis was performed with 500 ml drained and minimal improvement of symptoms. Due to significant response, she had a freeze all embryo cycle. On POD #5, she had worsening shortness of breath and underwent a CT pulmonary embolism (PE) protocol which did not demonstrate a PE but did show significant bilateral pleural effusions without abdominal ascites. She then underwent a bilateral thoracentesis with 800 ml drained from left lung and 1000 ml drained from right lung. She had significant improvement and returned to baseline after two days. CONCLUSIONS: OHSS is an uncommon side effect of gonadotropin stimulation, but this patient had multiple risk factors including age, PCOS diagnosis, AMH level, peak E2 level and number of oocytes retrieved. Ascites typically appears before pleural effusions. We postulate that the recent COVID-19 infection may have increased fluid accumulation preferentially to the lungs rather than the abdomen. IMPACT STATEMENT With the ever increasing knowledge of post- COVID conditions, one must consider its potential long-term sequalae. Unexpected or atypical presentations may be due to COVID-19. The physiologic changes that occur with fertility treatment may be exacerbated by recent, even mild, COVID-19 illness.