Oseltamivir and Remdesivir as a Targeted Combination Therapy for a Young and Previously Healthy Adult with Acute Respiratory Distress Syndrome Secondary to Flurona

ABSTRACT

Introduction/Background COVID-19 and influenza typically present in a very similar clinical picture. The co-infection of influenza among COVID-19 patients (i.e., flurona) can occur in the fall and winter of the year. The prevalence of flurona was estimated to be 0.4% and 4.5% in America and Asia, respectively. The damage of respiratory ciliated cells by the influenza virus can facilitate COVID-19 infection. Few studies reported COVID-19 co-infection with influenza virus. The majority of flurona cases affected older patients with co-morbidities. The co-infection of influenza among COVID-19 patients was associated with more severe disease, especially among older patients with co-morbidities. Young and healthy adults are less likely to develop severe COVID-19 leading to ARDS even with co-infection. However, severe COVID-19 can still occur regardless of age and co-morbidities. Herein, we report a case of severe ARDS in a young and previously healthy adult secondary to flurona that was successfully treated with targeted combination therapy with oseltamivir and remdesivir. Objective(s) A 21-year-old Caucasian male patient without significant past medical history presented the ED with a chief complaint of fatigue, cough, and generalized body aches. The patient mentioned that symptoms started a few days before his presentation. He suspected it was the flu, so he did not seek medical care initially. However, his symptoms continued to worsen, to the point that he could not move without getting severely out of breath. He was tachycardic, tachypneic in the emergency department (ED). His COVID-19 swab returned positive, and a respiratory pathogen panel was also positive for influenza A infection. Initial CTA was negative for PE but showed extensive multifocal bilateral infiltrates consistent with viral pneumonia. He was started on a high-flow nasal cannula. Still, his oxygen was peaking around 85% with increased work of breathing. The patient also did not tolerate BiPAP. Therefore, the patient was intubated in the ED and admitted to the intensive care unit (ICU). He was started on a five-day course of oseltamivir, remdesivir, and intravenous methylprednisolone. The patient remained intubated and mechanically ventilated on the next day, and PaO2/FIO2 ratio was 100. He was started on ARDS treatment protocol, and daily prone positioning was initiated. Gradually the patient started to improve. On day nine, he successfully passed a CPAP trial and was extubated. His ICU stay was complicated by the development of a small segmental PE that was treated with IV heparin. He also had upper GI bleeding, and esophagogastroduodenoscopy revealed a bleeding gastric ulcer, which was successfully managed with endoscopic clipping. The patient gradually improved, and his oxygen requirements decreased significantly over the next few days. He was discharged home with no supplemental oxygen on apixaban and pantoprazole. Methods Our study highlights the importance of screening for co-infecting influenza virus in COVID-19 patients, which could be the leading cause of disease severity. Early detection of flurona can play an important role in managing these patients, especially if they develop ARDS. Targeted combined therapy against influenza and COVID-19 with oseltamivir and remdesivir may effectively mitigate the morbidity and mortality of these patients. Improving compliance with flu vaccination is highly recommended to reduce influenza virus transmission during this long COVID-19 pandemic and reduce the risk of COVID-19 severity.