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Infectious Diseases II


Wednesday, October 29, 2003

2:00 PM - 3:30 PM

High Dose Intravenous Methylprednisolone in the Treatment of Severe Acute Respiratory Syndrome: A Case Report

Sharmistha Mishra, MD*, Winnie M. Lee, MD, MSc, Brian Bressler, MD, Stephen C. Juvet, MD and Denis Hadjiliadis, MD, MHS

University of Toronto, Toronto, ON, Canada

INTRODUCTION: This is a report of a case of probable severe acute respiratory syndrome (SARS) with use of pulse methylprednisolone as treatment.

CASE PRESENTATION: A 72 year-old female was assessed for fever. Her past medical history included a remote 30-pack year history of smoking. Three weeks prior to her admission, her husband was treated in the emergency department for atrial fibrillation. He returned nine days later with a febrile illness and respiratory symptoms consistent with SARS. Subsequently, it was determined that the person adjacent to his gurney during the initial visit was a member of the SARS index family in Toronto1.

Our patient presented with a two week history of fever and significant malaise.On admission, her respiratory rate was 16 breaths per minute, oxygen saturation 91% on room air, and her temperature was 38.9°C. Respiratory exam revealed bibasilar crackles.

Laboratory studies revealed: normal white blood cell count and differential, elevated creatine kinase (429U/L), and elevated lactate dehydrogenase (490U/L). The rest of her laboratory studies were unremarkable. Her arterial blood gas revealed: pH 7.55, PaO2 66mmHg, PaCO2 28mmHg. Her chest radiograph (Figure 1 ) was normal.



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Initial therapy consisted of intravenous (IV) ribavirin and gatifloxacin. She became afebrile on day three. However, a right mid-upper lung infiltrate occurred on day two of admission (Figure 2).

On day six, she developed a dry cough and dyspnea. By day ten she required 100% oxygen by face mask and her chest radiograph revealed extension of disease to her left lung (Figure 3 ). Therapy with IV methylprednisolone (60mg daily) and meropenem was initiated.



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There was no improvement clinically or radiographically by day fourteen (Figure 4 ). Pulse IV methylprednisolone 250mg daily for three days, followed by 60mg IV methylprednisolone daily was given. Ribavirin was re-initiated. Her clinical course stabilized until day 19, but she remained on 100% FiO2.



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DISCUSSION: SARS has become a global health issue. To date, there is no known effective treatment. IV ribavirin, corticosteroids, and broad-spectrum antibiotics have been tried12. To our knowledge, this is the first report of high dose IV corticosteroids in the treatment of SARS outside of Hong Kong.

Corticosteroids decrease inflammation and have been used in the treatment of other acute severe diffuse respiratory illnesses such as acute respiratory distress syndrome (ARDS)3, and bronchiolitis obliterans organizing pneumonia (BOOP)4 with acceptable results. Some patients with SARS develop diffuse lung infiltrates late in their course, which may be consistent with an inflammatory response to the original infection.

Our patient developed diffuse lung infiltrates and hypoxemia late after admission, while remaining afebrile. Pulse IV corticosteroids were used in an attempt to reverse the inflammatory process. This approach has been used successfully in treating some SARS patients in Hong Kong2.

CONCLUSION: On day 21, our patient died from a respiratory arrest. The autopsy findings were consistent with acute respiratory distress syndrome (ARDS). Further investigations are needed to determine the role of pulse dose corticosteroids in patients with SARS.

DISCLOSURE: S. Mishra, None.

REFERENCES

  1. Poutanen SM, Low DE, Henry B, et al. Identification of severe acute respiratory syndrome in Canada. N Eng J Med 2003. Available at http://content.nejm.org
  2. Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Eng J Med. Available at http://content.nejm.org
  3. Meduri GU, Headley AS, Golden E, et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA280(2)1998159–165
  4. Epler GR., Bronchiolitis obliterans organizing pneumonia. Arch Intern Med. 2001;161:158–164





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