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   Table of Contents      
LETTER TO THE EDITOR
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 97-98

A case of COVID-19 with pulmonary sequelae


Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission27-Nov-2020
Date of Decision30-Nov-2020
Date of Acceptance22-Jan-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_122_20

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How to cite this article:
Virk BS, Gupta N, Malhotra N, Ish P. A case of COVID-19 with pulmonary sequelae. MAMC J Med Sci 2021;7:97-8

How to cite this URL:
Virk BS, Gupta N, Malhotra N, Ish P. A case of COVID-19 with pulmonary sequelae. MAMC J Med Sci [serial online] 2021 [cited 2021 Oct 24];7:97-8. Available from: https://www.mamcjms.in/text.asp?2021/7/1/97/314878



To,

The Editor

A 62-year-old lady presented with fever and dry cough for 3 days and was diagnosed with COVID-19 by nasopharyngeal swab-based reverse transcriptase-polymerase chain reaction (RT-PCR) test. She had no comorbidities or past history of any respiratory disorder. She developed dyspnea on day 3 of illness and presented with hypoxemia. Her chest radiology showed bilateral pneumonia with a CT chest suggestive of bilateral peripheral ground-glass opacities [Figure 1]A and 1B. She was admitted and treated with oxygen, parenteral methylprednisolone, Remdesivir, and enoxaparin as per national guidelines. She was maintaining saturation of 94% on 4-liter oxygen and did not require non-invasive or invasive mechanical ventilation. She had lymphopenia with raised lactate dehydrogenase (LDH) and preserved liver and kidney functions. Throughout the admission, the patient maintained her blood pressure and was afebrile. The patient improved and was discharged on day 20 of admission with a saturation of 94% on room air.
Figure 1 (A and B) CT Chest showing bilateral peripheral ground-glass opacities in basal regions suggestive of viral infection. (C and D) CT chest showing bilateral subpleural ground glassing with intra- and interlobular septal thickening, parenchymal bands, and extensive cystic changes with predominant basal distribution. Associated fusiform bronchiectasis noted bilaterally in the lower lobe

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On follow-up in the outpatient department (OPD) after 4 weeks, she complained of persistent dyspnea with no upper respiratory symptoms or fever. She had a fall in saturation to 90% (94% on discharge 1 month back) with tachypnea and tachycardia. A repeat CT chest was suggestive of marked architectural distortion, tractional bronchiectasis, parenchymal bands, inter and intralobular septal thickening, and extensive cystic changes in bilateral lower lobes [Figure 1]C and 1D. The patient was prescribed oral prednisolone at 0.5 mg/kg for 4 weeks and had symptomatic relief with an improvement of saturation from 90% to 94%. A detailed discussion with the patient was done and she was given an informed choice for starting antifibrotic. However, in view of symptomatic improvement, she declined and was advised to remain in the follow-up.

Radiology in COVID-19 has been documented to be imperative in assisting in making a diagnosis, prognosis, and assessing long-term sequelae. The most common CT feature of COVID-19 is ground-glass opacities, in a peripheral, sub-pleural lower lobe distribution. Reverse halo sign suggesting organizing pneumonia and crazy paving pattern can also be seen in early disease. Progression of CT involvement in non-severe patients has been divided into four stages (early stage during first 4 days after onset of symptoms, progressive stage from 5 to 8 days, peak stage 9 to 13 days, and absorption stage seen after 14 days). The severity of lesions has been seen to peak at 10 days.[1] Reticular pattern, Interstitial thickening, irregular interface, and parenchymal band are considered predictors of pulmonary fibrosis with the latter two indicating early features of fibrosis. Patients likely to progress to pulmonary fibrosis have been found to be older, with a prolonged hospital stay, longer duration of disease, having received pulse steroids for a longer duration, high lactate dehydrogenase, high highly sensitive CRP levels, and lower lymphocyte counts.[2] Our patient also had a similar presentation.

Alveolar epithelial cell injury leading to fibrosis has been proposed as a possible mechanism in post-COVID-19 fibrosis. However, similar to idiopathic pulmonary fibrosis (IPF), transforming growth factor-beta, tumor necrosis factor-alpha, fibroblast growth factor, and platelet-derived growth factor may play a role in pathogenesis.[3] Hence, it is proposed that antifibrotics like pirfenidone and nintedanib may prove to be useful in post-COVID-19 fibrosis but timing and target patients need to be addressed. Isolated case studies have shown improvement in post-inflammatory fibrosis after COVID-19 with short-term use of pirfenidone.[4] Antifibrotics have been shown to inhibit IL-6 involved in cytokine storm.[5]

However, in the absence of any proven long-term benefit of antifibrotics in post-COVID-19 fibrosis and the unknown progression potential of such fibrosis, starting antifibrotics must be an informed choice and ideally only as a part of trial till further evidence.[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pan F, Ye T, Sun P et al. Time course of lung changes at chest CT during recovery from coronavirus disease2019 (COVID-19). Radiology 2020;295:715-21.  Back to cited text no. 1
    
2.
Yu M, Liu Y, Xu D et al. Prediction of the development of pulmonary fibrosis using serial thin-section CT and clinical features in patients discharged after treatment for COVID-19 pneumonia. Korean J Radiol 2020;21:746-55.  Back to cited text no. 2
    
3.
Lechowicz K, Drożdżal S, Machaj F et al. COVID-19: the potential treatment of pulmonary fibrosis associated with SARS-CoV-2 infection. J Clin Med 2020;9:1917.  Back to cited text no. 3
    
4.
Xi Z, Zhigang Z, Ting L. Post-inflammatory pulmonary fibrosis in a discharged COVID-19 patient: effectively treated with pirfenidone. Arch Pulmonol Respir Care 2020;6:051-053.  Back to cited text no. 4
    
5.
George PM, Wells AU, Jenkins RG. Pulmonary fibrosis and COVID-19: the potential role for antifibrotic therapy. Lancet Respir Med 2020;8:807-15.  Back to cited text no. 5
    
6.
Vasarmidi E, Tsitoura E, Spandidos DA et al. Pulmonary fibrosis in the aftermath of the COVID-19 era (Review). Exp Ther Med 2020;20:2557-60.  Back to cited text no. 6
    


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