Internal Medicine Journal | 2021
Late presentation of organising pneumonia in COVID‐19
Abstract
A 58-year-old man developed coryzal symptoms, temperature and systemic malaise and had a positive swab for COVID-19. He presented to the hospital and was hypoxic; a chest X-ray demonstrated a widespread infiltrate. He was admitted to the intensive care unit (ICU) and was commenced on dexamethasone at 6 mg daily and remdesivir with high-flow oxygen. He was initially markedly hypoxic with a nadir saturation of 81% recorded, while on 50% oxygen. His hypoxia improved in the ICU and after 4 days he was transferred to the standard ward with supplemental oxygen. After 8 days, his dexamethasone was ceased and he was discharged home. He was subsequently reviewed 2 months after discharge and he was still complaining of significant symptoms of dyspnoea, cough and malaise. There were no other obvious features of long COVID-19. A computed tomography (CT) scan done after review demonstrated widespread ground-glass infiltrates (Fig. 1). Lung function testing demonstrated normal lung volumes with a forced expiratory volume in 1 s (FEV1) of 90% of predicted, a forced vital capacity (FVC) of 88% of predicted and a reduced lung diffusing capacity for carbon monoxide (DLCO) at 68% of predicted. The features were consistent with organising pneumonia (OP). He was treated with a moderate dose of 25 mg of prednisolone daily. He remained on the same dose and was reviewed 2 months later. At that time, he felt that his symptoms had resolved and he had gone back to work. His lung function demonstrated a marked improvement with FEV1 of 107% predicted, FVC of 102% predicted and DLCO of 96% predicted. A repeat CT demonstrated significant improvement in the ground-glass infiltrates. He was prescribed a weaning dose of prednisolone. A proportion of patients develop a variety of chronic symptoms beyond the initial acute illness; this has been designated as ‘long COVID-19’. Respiratory manifestations are a prominent component of this syndrome, although the number of published studies is relatively limited. OP is a relatively rare condition characterised by persistent respiratory symptoms, patchy ground-glass infiltrate on CT and specific pathological lesions, that may cause permanent lung damage if untreated. Reports have described OP occurring in patients first presenting to the hospital with COVID-19 and responding to prednisolone. The patient in the current report is a little different than that described in the other studies in that he received the currently recommended therapy of dexamethasone and presented 2 months after discharge. The patient did not have a pathologic confirmation of OP, although the clinical and radiological features were consistent with this condition. There are very limited guidelines available as to how long COVID-19 should be managed. Recent guidelines from the UK-based National Institute for Health and Care Excellence