Use of High Dose Corticosteroids Reversed COVID-19 Associated ARDS in a Patient Listed for Lung Transplantation

In acute respiratory distress syndrome (ARDS) patients with irreversible lung damage, lung transplantation from a ventilator and/or extracorporeal membrane oxygenation support (ECMO) is feasible. Recently, selection criteria for lung transplant candidates with a COVID-19 associated ARDS have been published. Here, we report the efficacy of high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation. A 50-year-old female with a medical history of Multiple Sclerosis (relapsing-remitting type under treatment with anti-alpha4 -integrin therapy), was tested positive for COVID-19. She deteriorated and was admitted to the hospital. High flow oxygen and dexamethasone (six milligram daily), were started but unfortunately, she developed a severe ARDS with need for mechanical ventilation and ECMO support. Corticosteroids according to the Meduri scheme and ciprofloxacin were started. Weaning trials were initiated but failed and CT-thorax showed consolidation and presumed fibrosis. After 37 days on ECMO, she was evaluated and listed for bilateral lung transplantation. A corticosteroid pulse therapy of 1000 mg of methylprednisolone IV for three days during antibiotic coverage with piperacillin/tazobactam was started and within three days the clinical condition of the patient improved and she could be weaned from ECMO (51 days of ECMO) and delisted from the lung transplantation waiting list. Nowadays, patient does not require oxygen, is at home and revalidating. Here, we report the efficacy of a regimen with high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation. Corticosteroids are beneficial for immunomodulation and may reduce hyperinflammation. Our trial with administration of high dose corticosteroids pulse therapy in COVID-19 ARDS patients refractory to corticosteroids according to “classical schemes” has been successful and is informative. Further studies, will hopefully further elucidate responders and non-responders to high dose corticosteroid pulse therapy and preferably answer the question if prophylactic use of antibiotics and antifungals (in view of possible complications such as pulmonary aspergillosis and mucormycosis) is prudent in this vulnerable group.