|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 97-98
A case of COVID-19 with pulmonary sequelae
Baljeet Singh Virk, Nitesh Gupta, Nipun Malhotra, Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||27-Nov-2020|
|Date of Decision||30-Nov-2020|
|Date of Acceptance||22-Jan-2021|
|Date of Web Publication||28-Apr-2021|
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|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
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. 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. 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. 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. Antifibrotics have been shown to inhibit IL-6 involved in cytokine storm.
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.
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Conflicts of interest
There are no conflicts of interest.
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