COMPLICATIONS OF HIGH-DOSE STEROIDS IN COVID-19

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The novel coronavirus disease (COVID-19) has been associated with diffuse lung injury. Corticosteroids have been shown to suppress inflammation-mediated lung injury and as a result, decrease progression to respiratory failure. Based on the RECOVERY trial, the use of dexamethasone in patients hospitalized with COVID-19 resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or supplemental oxygen at randomization [1]. Per IDSA treatment guidelines dexamethasone use in hospitalized patients is strongly recommended, thereby prompting most intuitions in the United States and worldwide to initiate its use. We present a unique case of Nocardia farcinica brain abscess in the setting of prolonged dexamethasone use in a patient with COVID-19 infection. CASE PRESENTATION: 80-year-old female from Pakistan with a past medical history of hypertension, who while in Pakistan was diagnosed with COVID-19 and treated with Xarelto and dexamethasone (dose and duration unknown). Her course was complicated by the development of left elbow and hand Zoster and over the 10 days prior to presentation, she was noted to develop increasing left-sided weakness and aphasia. Patient was transferred to the United States where a CT scan revealed a left frontal mass, prompting transfer to a tertiary care facility. MRI brain revealed a left frontal cystic rim-enhancing lesion that was concerning for a brain abscess. The patient subsequently underwent left frontal stereotactic brain biopsy with recovery of 3 mL of purulent fluid. Gram staining revealed beaded branching gram-positive rods. She was initially placed on vancomycin/cefepime/metronidazole/dexamethasone and was changed to IV Bactrim/ceftriaxone/doxycycline to cover for Nocardia and Actinomyces. Modified acid-fast stain returned positive with beaded, branching, filamentous rods, consistent with Nocardia. Cultures returned with Nocardia farcinica. DISCUSSION: Nocardia infection primarily occurs via inhalation or direct skin inoculation and subsequently disseminates hematogenously to end organs, which include the brain [2]. Nocardia typically presents as a respiratory or skin infection;brain abscesses are rare and primarily found in immunocompromised patients. As outlined in this case, an immunocompromised state was induced by high dose steroid use. Corticosteroids modulate inflammatory mediators and thereby cause immunosuppression. New symptoms should be monitored closely in patients undergoing steroid therapy, as seen in our patient who presented with new onset aphasia and left sided weakness. This is especially true during the COVID-19 pandemic that has prompted widespread use of dexamethasone in order to prevent respiratory failure and death. CONCLUSIONS: Physicians should be vigilant of superimposed infections in patients with COVID-19 receiving high dose steroids. REFERENCE #1: RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med. 2021;384(8):693-704. doi:10.1056/NEJMoa2021436. REFERENCE #2: Lin YJ, Yang KY, Ho JT, Lee TC, Wang HC, Su FW. Nocardial brain abscess. J Clin Neurosci. 2010;17(2):250-253. doi:10.1016/j.jocn.2009.01.032 DISCLOSURES: No relevant relationships by Waqas Bhatti, source=Web Response No relevant relationships by Tanisha Kaur, source=Web Response