Reactions Weekly | 2021
Antibacterials/convalescent-anti-SARS-CoV-2-plasma/remdesivir
Abstract
Treatment failure and off-label use: case report A 57-year-old man exhibited treatment failure during an off-label treatment with convalescent-anti-SARS-CoV-2-plasma for coronavirus disease 2019 (COVID-19). Additionally, he exhibited treatment failure with remdesivir, while being treated for COVID-19. Also, he received off-label treatment with levofloxacin and azithromycin for COVID-19 with no associated ADR [dosages and routes not stated]. The man, who had a history of aortic valve stenosis, status post aortic valve replacement and stented porcine bioprosthesis, was evaluated in a COVID-19 clinic. Approximately 2 weeks later, he developed fever, myalgias, dry cough and arthralgias. He additionally developed right-sided pleuritic chest pain and bilateral pneumonia. Based on these symptoms, COVID-19 was suspected. However, a rapid-antigen COVID-19 test was found to be negative. He was sent home on an off-label treatment with levofloxacin and azithromycin for suspected COVID-19. Additionally, he was receiving dexamethasone, rivaroxaban and ticagrelor concomitantly. However, his symptoms persisted, and he re-presented to the local hospital. A repeat COVID-19 test was found to be negative. Thereafter, he requested himself to be transferred to the medical centre. On admission, the laboratory findings revealed diffuse ground glass opacities with a ’crazy paving’ pattern, which was consistent with COVID-19. Therefore, he received treatment with remdesivir. He additionally received an off-label treatment with convalescent-anti-SARS-CoV-2-plasma [convalescent plasma]. Also, he received empirical treatment with dexamethasone. However, despite treatment with remdesivir and convalescent-antiSARS-CoV-2-plasma, his condition failed to improve after 2 days with persistent hypoxaemia. Thus, treatment failure with remdesivir and convalescent-anti-SARS-CoV-2-plasma was considered. As a result, he required continuous supplemental oxygen. Due to the development of hypoxic respiratory failure, a flexible fiberoptic bronchoscopy was scheduled, and he was endotracheally intubated for the procedure. At this time, both antigen-based and polymerase chain reaction-based COVID-19 tests were found to be positive. After successful exubation, his condition was found to be similar to his pre-procedural condition for several hours. Additionally, he was found to have mild right ventricular dilatation, systolic hypokinesis, worsening respiratory distress and hypoxaemia. Therefore, he underwent non-invasive mechanical ventilation. As his current respiratory support was insufficient to achieve effective exchange, extracorporeal membrane oxygenation was cannulated. As a result, right ventricular mechanical circulatory support was provided. He was then transferred to the cardiac catheterisation laboratory. The right internal jugular vein was percutaneously cannulated and a pulmonary artery catheter was placed. His remaining hospital course was uneventful, and he was discharged home in good condition 3 days after decannulation. On follow-up one month later, he was doing well.