A Case of Effective Intravenous Methylprednisolone Pulse Therapy for Severe COVID-19 Infection After Arteriovenous Transplant Surgery – Kamata – 2022 – Respiratory Case Reports


INTRODUCTION

COVID-19 infections in patients with end-stage kidney disease (ESRD) are more likely to become serious than in other patients, with a high death rate.1 Of the therapeutic agents known to be effective, only corticosteroids can be used in patients with ESRD, severely limiting the treatment options. Although low dose corticosteroid therapy is recommended,2 The efficacy and safety of high-dose corticosteroid therapy in combination with pulse therapy with intravenous methylprednisolone (pulse therapy) has not been confirmed. We have seen one case of ESRD in which infection with COVID-19 immediately followed arteriovenous graft surgery (AVG). Although respiratory status deteriorated after administration of dexamethasone, requiring invasive mechanical ventilation, pulse therapy was effective. We report here the results of this case as well as bibliographical considerations.

CASE REPORT

A 66-year-old man developed diverticulitis 7 years ago, when mild kidney dysfunction was noted. His kidney function gradually deteriorated and he was treated twice in hospital, with hydrops seen 6 months ago. Shortness of breath on exertion appeared 2 weeks ago. Laboratory tests revealed an elevated serum creatinine level of 7.08 mg / dl and a decreased hemoglobin level of 6.5 mg / dl. Therefore, creation of vascular access and initiation of dialysis was deemed necessary. As our facility was in a state of emergency, reverse transcription polymerase chain reaction (PCR) with a nasopharyngeal swab was performed on admission, showing negative results. The systemic edema and anemia were severe, so he received loop diuretics for the treatment of the edema and a blood transfusion of 6 units of red blood cell concentrate before surgery. One week after admission, AVG surgery was performed under laryngeal mask anesthesia combined with intravenous sedation. On day 1 following surgery, a fever> 38 ° C was observed, followed by a fatty cough on day 3, resulting in a positive PCR test indicating infection with COVID-19. Computed tomography (CT) of the chest revealed multiple uneven shadows resembling ground glass throughout the bilateral lungs (Figure 1A, B). He received 2 L / min nasal cannula support, intravenous dexamethasone (6 mg once daily) and antibiotic prophylaxis. His respiratory state deteriorated sharply on the 7th postoperative day, requiring ventilatory management. He underwent dialysis with a central venous catheter the same day. The tidal volume was large, so deep sedation was performed to suppress subsequent lung damage, with a positive expiratory pressure set to approximately 8-10 cmH2O. However, the partial pressure of arterial oxygen relative to fractionated inspired oxygen (PaO2/ FiO2; PF) gradually deteriorated to 100 units, and granular shadows were seen throughout the lung field on the chest x-ray (Figure 2A). Because he developed severe hypoxemic respiratory failure due to acute respiratory distress syndrome (ARDS), 500 mg of methylprednisolone was infused intravenously daily for 3 days from postoperative day 10. 400 units, while the chest x-ray showed a marked improvement in patency (Figure 2B). The patient was able to be weaned from the ventilator the same day. In the lab test, the value of C reactive protein was elevated to 15.1 before pulse therapy, but it significantly decreased to 2.8 after 4 days of therapy. After the pulse therapy, the patient received treatment with oral corticosteroids (prednisone 40 mg once a day, 0.5 mg / kg, weight 80 kg). On postoperative day 20, administration of oxygen became unnecessary and quarantine was lifted on postoperative day 28, with the cannulated forearm graft for dialysis thereafter. Chest computed tomography revealed only fibrosis in the left upper lobe (Figure 1C, D). After that, the corticosteroid dose was reduced by 10 mg / day, every 2 weeks.

Chest computed tomography (CT) on postoperative day 3 (A, B) showed uneven shadows resembling ground glass (white arrows), pericardial fluid, and bilateral pleural effusion in both lungs. On postoperative day 28, chest CT scan (C, D), pleural effusion was decreased compared to the onset of COVID-19 infection, with only mild post-pneumonic fibrosis (white arrow) observed in the upper lobe left

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Although grainy shadows (A) were observed throughout the lung field due to exacerbation of COVID-19 infection, improved patency (B) was observed using pulse therapy

DISCUSSION

The case fatality rate for COVID-19 infection in patients with ESRD is estimated to be 20-30%.1, 2 The currently approved therapeutic agents in Japan are remdesivir, steroids and baricitinib; however, only steroid therapy is possible in patients with ESRD. Although low dose corticosteroid therapy was given at the moderate stage in this case, the respiratory status deteriorated, possibly requiring management of ventilation. Although hemodialysis was initiated, after the start of ventilator use the patient developed severe hypoxemic respiratory failure due to ARDS which made his condition extremely serious. Edalatifard et al.3 conducted a prospective study of pulse therapy in patients with severe COVID-19 infection and showed that mortality was significantly reduced in the pulse steroid group (5.9% in the administration group versus 42.9% in the standard treatment group). Although this study was not conducted in patients with ESRD, we suspected that steroid pulses might be effective in patients with ESRD.

The case fatality rate of COVID-19 patients during the perioperative period was 20%, indicating a very poor prognosis.4 In addition to ensuring patient safety, surgeons should perform elective surgical procedures and perioperative management while considering minimizing the risk of infection among healthcare professionals. The surgical triage recommended by the American College of Surgeons is known to determine whether to initiate or postpone elective surgery. Because this patient suffered from severe ESRD, in addition to also suffering from respiratory failure, he was considered to be in stage 3, a condition which required careful surgery while taking sufficient infection prevention measures, so that the operation itself was considered appropriate. PCR tests were performed at the time of admission to our hospital for all patients undergoing elective surgery to prevent infection, and the test for this patient was negative at that time. The present patient required treatment for the edema and blood transfusion prior to the surgery, which lasted for one week. It is quite possible that he was exposed to the virus while in hospital after admission and developed the infection the day after surgery. COVID-19 infection was confirmed among her hospital roommates in the preoperative admission room, as well as among staff who were active there. Fortunately, the surgeon and the anesthesiologist who conducted the therapy were not infected with COVID-19. The incubation period for COVID-19 infections is said to be 1 to 14 days. In addition, the incidence of asymptomatic infections is believed to be more frequent than that of influenza, ranging from single-digit percentages to 60%.5 In view of these points, the PCR test should have been performed again on this patient immediately before the operation.

CONFLICT OF INTEREST

None declared.

AUTHOR’S CONTRIBUTION

Sokichi Kamata and Kiyohiro Fujiwara designed this report and wrote the manuscript. Sokichi Kamata and Souhei Hamanaka performed AVG surgery. Jin Tsukamoto, Teppei Tsuchimoto, and Mikio Okamura assisted in the patient’s therapy. All authors participated in the drafting of the manuscript and approved the final version of the manuscript.

ETHICAL STATEMENT

The authors state that appropriate written informed consent has been obtained for the publication of this case report and accompanying images.

THE REFERENCES

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