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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 5  |  Page : 93-95

Lifesaving combined treatment in a rapidly progressive COVID-19 pneumonia case with extensive lung involvement


1 Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
3 Clinical Tuberculosis and Epidemiology Research Centre, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Mycobacteriology Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Submission15-Jun-2020
Date of Acceptance15-Jul-2020
Date of Web Publication13-Aug-2020

Correspondence Address:
Dr. Seyed Mohammad Reza Hashemian
Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_134_20

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  Abstract 


COVID-19 pneumonia has rapid development into a global pandemic. For the infected patients, it is an urgent matter to improve the cure rate and reduce the death rate, but there are no effective antiviral drugs for COVID-19 so far. There is an urgent need for effective treatment. The current focus has been on the development of novel therapeutics, including antivirals and vaccines. One of these drugs, Favipiravir (Avigan), an antiviral agent approved for use in influenza in Japan, is being studied for the treatment of COVID-19. Herein, we report a patient; a 53 Y/O man without any underlying disease, developed COVID19 pneumonia rapidly and well respond to combination treatment including Dexamethasone, Favipiravir, and IFN-β-1a.

Keywords: Covid-19, combined treatment, pneumonia, global pandemic


How to cite this article:
Hashemian SM, Farrokhi R, Tabarsi P, Jamaati H, Velayati AA. Lifesaving combined treatment in a rapidly progressive COVID-19 pneumonia case with extensive lung involvement. Biomed Biotechnol Res J 2020;4, Suppl S1:93-5

How to cite this URL:
Hashemian SM, Farrokhi R, Tabarsi P, Jamaati H, Velayati AA. Lifesaving combined treatment in a rapidly progressive COVID-19 pneumonia case with extensive lung involvement. Biomed Biotechnol Res J [serial online] 2020 [cited 2022 Aug 14];4, Suppl S1:93-5. Available from: https://www.bmbtrj.org/text.asp?2020/4/5/93/292083




  Introduction Top


At the end of 2019, COVID-19 was confirmed to have developed a cluster of pneumonia patients in Wuhan, Hubei Province, China, and has since spread throughout China and has spread worldwide.[1] Its mortality rate is about 3.7% compared to influenza with less than 1%. There is an urgent need for effective treatment. The current focus has been on the development of novel therapeutics, including antivirals and vaccines.[2] One of these drugs, favipiravir (Avigan), an antiviral agent approved for use in influenza in Japan, is being studied for the treatment of COVID-19.[3]

Herein, we report a 53-year-old male patient without any underlying disease, developed COVID-19 pneumonia rapidly, and well respond to combination treatment including dexamethasone, favipiravir, and interferon beta (IFN-β)-1a.


  Case Report Top


A 53-year-old male (height 178 cm, weight 100 kg, and BMI = 31.5) with a 10-day history of mild fever, myalgia, and general weakness followed by cough and respiratory distress presented to the emergency department. The patient had no significant medical history. His symptoms showed up with diarrhea on the 1st day followed by progressive headache. On day six (D6) of illness, he had done chest computed tomography (CT) scan as an outpatient in another medical center [Figure 1]a; showed few round consolidations in both the lungs, he was also diagnosed with 94% O2 saturation at the same time. Then, he used azithromycin 250 mg bid. Despite treatment, the symptoms worsened and he became more ill. Nonproductive cough and difficulty breathing added to his symptoms so on D11 he was brought to our hospital emergency department. On admission, the physical examination revealed body temperature: 37.5°C, respiratory rate: 32 breaths/min, SpO2: 79% (room air), heart rate: 50 beats/min, and a blood pressure of 110/75 mmHg. He was given blood routine examination and lung spiral CT scan [Figure 1]b showed multiple, ground-glass opacities and massive consolidation located in both the lungs [Figure 1]b. The laboratory tests showed mild changes, including leukopenia (3,900/uL) and thrombocytopenia (101,000/uL) and increased inflammatory markers (erythrocyte sedimentation rate: 20 mm, C-reactive protein: 51 mg/l) [Table 1]. He hospitalized in an isolation room. The SARS-CoV-2 was confirmed by real-time reverse transcription polymerase chain reaction test from nasopharyngeal swabs. During admission, the patient supplied with oxygen at a flow rate of 10 l/min and treated with Amp dexamethasone 8 mg daily (from D1 of admission) and the very next day he received tablet favipiravir 200 mg (1600 mg twice daily on day 1 and 600 mg twice daily for seven more days) and Amp IFN-β-1a/2 IU/SC for three days. The following day due to worsening oxygen saturation (60% in room air and 85% with 10 l/min oxygen supplement), BIPAP ventilation was started for him. The patient was evaluated for cytokine storm and IL6 = 4.2 Pg/ml (reference value up to 5.9) was reported. Eventually, 48 h after treatment with favipiravir and BIPAP ventilation (D4 of admission, D15 of illness), he experienced clinical improvement. His respiratory distress resolved, and oxygen requirements were weaned back to 3–5 l/min. Chest X-ray [Figure 2] done for him demonstrated bilateral alveolar consolidation predominantly in the lower lobes of both the lungs. Compared to the previous imaging [Figure 1]b, evidence of recovery was seen. After discharge (D24 of illness), repeated CT-scan done for him revealed bilateral scattered ground-glass opacities; No signs of extensive consolidation and significant changes (symptoms resolved) were observed compared to previous imaging [Figure 3].
Figure 1: Axial view of a lung CT. (a) D6 of illness: revealed few bilateral patchy opacities just seen in lower regions. (b) D11 of illness/D1 of admission: revealed bilateral ground-glass opacities and massive consolidation located in both lungs

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Table 1: Blood tests

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Figure 2: Chest X-ray (anteroposterior view), showing bilateral alveolar consolidation predominantly in lower lobes of both lungs.(D4 of addmision )

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Figure 3: Axial view of a lung CT, showing bilateral scattered ground-glass opacities, indicating resolved changes compared to previous imaging. (D24 of illness, after discharge)

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  Discussion Top


COVID-19 pneumonia has rapid development into a global pandemic. For the infected patients, it is an urgent matter to improve the cure rate and reduce the death rate, but there are no effective antiviral drugs for COVID-19 so far.[3] The current focus has been on the development of novel therapeutics, including antivirals and vaccines. One of these medicines, favipiravir (Trade name: Avigan), an antiviral agent approved for use in influenza in Japan, is being studied for the treatment of COVID-19.[4]

The patient we discussed initially had no underlying disease or even respiratory symptoms, then, despite oxygen therapy, extensive lung involvement progressed rapidly. The patient started treatment with dexamethasone and receiving an initial dose of IFN-β-1a that made the patient's condition worse. Then, favipiravir was added to the treatment, and after 48 h, the patient's symptoms dramatically resolved.

Recently, Chen et al.[3] carried out a prospective multicenter open-labeled randomized superiority clinical trial of favipiravir (116 patients) versus umifenovir (120 patients) for COVID-19 patients in Wuhan, China. They found that in patients with moderate COVID-19 infections (who had not received any prior antivirals), favipiravir showed superior efficacy in terms of the rate of clinical recovery at day 7 and reduced the incidence of fever and cough.[3]

Another study done in China (non-randomized trial) identified a significant reduction in the time to SARS-CoV-2 viral clearance in patients treated with favipiravir. Patients in the intervention received favipiravir 1600 mg orally twice daily on day 1, followed by 600 mg orally twice daily on days 2–14 with inhaled IFN-α1b 60 μg twice daily and therapy was continued until viral clearance, up to a maximum of 14 days. There was a significant reduction in the median time to viral clearance with favipiravir (4 days), and by day 14, 91.4% of patients in the favipiravir arm had radiographic improvement.[5]

Several other clinical trials of favipiravir in COVID-19 patients have already started. Some of the trials are using favipiravir in combination with other antiviral or anti-inflammatory agents (as our patient). There is hope that these results should help further clarify the role of favipiravir in the treatment of COVID-19 patients.[6]


  Conclusion Top


Knowledge about the treatment of COVID-19 is accumulating at a rapid pace. Favipiravir with its effective results in many reports is still under investigation, and in some countries, it has not yet been included in the treatment protocols. In our patient with extensive and diffuse lung involvement and progressive condition, the combined treatment including dexamethasone, favipiravir, and IFN-β-1a could reverse the symptoms and save the patient. However, further knowledge of the effectiveness or possible side effects of any of these drugs in the treatment of COVID-19 have to be waited for in future studies, but we believe that it worth sharing information on early treatment to improve the prognosis of patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 1
    
2.
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.  Back to cited text no. 2
    
3.
Chen C, Zhang Y, Huang J, Yin P, Cheng Z, Wu J, et al. Favipiravir versus Arbidol for COVID-19: A randomized clinical trial. medRxiv (preprint) 2020. doi: https://doi.org/10.1101/2020.03.17.20037432.  Back to cited text no. 3
    
4.
Mishima E, Anzai N, Miyazaki M, Abe T. Uric acid elevation by favipiravir, an antiviral drug. Tohoku J Exp Med 2020;251:87-90.  Back to cited text no. 4
    
5.
Coomes EA, Haghbayan H. Favipiravir, an antiviral for COVID-19? J Antimicrob Chemother 2020;75:2013-4.  Back to cited text no. 5
    
6.
Seneviratne SL, Abeysuriya V, de Mel S, De Zoysa I, Niloofa R. Favipiravir in COVID-19. Int J Prog Sci Technol 2020;19:143-5.  Back to cited text no. 6
    


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