Reactions 1871, p145 - 4 Sep 2021

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Reactions 1871, p145 - 4 Sep 2021

Dexamethasone/favipiravir/antibacterials

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Cytomegalovirus pneumonia, Candida parapsilosis infection and off label use: case report

An 80-year-old woman developed Cytomegalovirus (CMV) pneumonia and Candida parapsilosis infection during off label treatment with dexamethasone for Coronavirus disease 2019 (COVID-19). Additionally, she received off label treatment with favipiravir on a compassionate use basis and unspecified antibacterials for COVID-19 with no associated ADR [routes and time to reactions onset not stated; not all dosages stated].

The woman, who had various comorbidities, presented to the emergency department with a one-week history of high fever and dry cough. Based on various investigations, she was diagnosed with COVID-19. Subsequently, she was admitted and started receiving off label treatment with dexamethasone 6mg daily and favipiravir on a compassionate use basis along with supplemental oxygen therapy. However, after three days, she was shifted to the ICU and mechanically ventilated due to respiratory failure. Her treatment with dexamethasone was continued, and she received treatment with remdesivir and off label therapy with unspecified antibacterials [antibiotics] additionally. Her chest infiltration and respiratory condition improved, and after seven days of mechanical ventilation (MV), she was extubated. Following 10 days, dexamethasone was discontinued. However, in the next two days she developed fever and rapidly progressive hypoxaemia. Subsequently, she was reintubated. Due to the possibility that COVID-19 related inflammation had relapsed, she again received dexamethasone 6mg daily with subsequent, gradual improvement of the chest shadows. Thereafter, the dexamethasone was tapered on a weekly basis. On the ninth day following reintubation, the chest shadows deteriorated again. Her serum β-D-glucan was found to be increased. Then, she started receiving empirical treatment with micafungin and cotrimoxazole [trimethoprim/sulfamethoxazole]. Blood culture revealed Candida parapsilosis. Therefore, her treatment with micafungin was changed to fosfluconazole. The treatment with cotrimoxazole was discontinued after PCR revealed negative result for Pneumocystis jirovecii. Her serum β-D glucan decreased, and six days after the initial culture, a follow-up blood culture revealed negative result for Candida. However, her respiratory condition and the chest shadows continued to deteriorated. A repeat screening test for co-infection was performed. The CMV antigenaemia assay for identifying pp65 antigen in peripheral blood leucocytes was increased. Based on these findings and clinical presentation it was concluded that the CMV pneumonia was the cause of her bilateral chest infiltrations and worsening of respiratory failure.

The woman was treated with ganciclovir. However, four days after the positive CMV antigenaemia test result, she died due to CMV pneumonia. Approximately 3h following her death, needle autopsy from the lung was performed, which revealed CMV infected cells. This confirmed the diagnosis of CMV pneumonia.

Amiya S, et al. Fatal cytomegalovirus pneumonia in a critically ill patient with COVID-19. Respirology Case Reports 9: No. 7, Jul 2021. Available from: URL: https://

onlinelibrary.wiley.com/doi/10.1002/rcr2.801 803592375