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?:abstract
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Introduction: Treatment for SARS-CoV-2 has targeted both the infection, and also inflammatory complications of Coronavirus Disease 2019 (COVID-19) Attempts to control associated hyper-inflammation can cause significant co-morbidities Specifically, immunomodulation in the setting of COVID-19 can result in co-infection with other pathogens Case Presentation: A 14-year-old female with combined immunodeficiency secondary to NFκB2 haploinsufficiency (p R853x) complicated by alopecia totalis, granulomatous dermatitis, arthritis, uveitis, and non-cholestatic hepatitis was diagnosed with COVID-19 pneumonia and cytomegalovirus (CMV) viremia She presented with fever, cough and acute dyspnea requiring high flow nasal cannula (HFNC) Imaging confirmed multifocal pneumonia and she tested SARS-CoV-2+ Her chronic adalimumab was held, and she was treated with dexamethasone and convalescent plasma Worsening respiratory distress prompted further immunomodulation with anakinra Remdesivir was administered only after improvement in her liver biochemistries She was weaned to room air, but abruptly developed new fevers and tachypnea again requiring HFNC;further testing revealed CMV viremia and pneumonitis Ganciclovir, foscarnet, CMV-IgG and additional anakinra therapy led to clinical improvement Discussion: Although immunomodulation may play an important role in COVID-19 treatment, broad immunomodulation herein likely contributed to reactivation of CMV Dexamethasone further weakened our patient’s already dysregulated T-cell response, increasing vulnerability to CMV reactivation Anakinra appeared to dampen her presumed dysregulated pulmonary inflammation and did not hinder the clearance of CMV This case highlights that it is critical to perform a detailed infectious evaluation in at-risk patients Additionally, anakinra is a promising immunomodulator for COVID-19, even in patients with concomitant infections
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