Pourshahid Seyedmohammad, Khademolhosseini Sara, Giri Badri, Cossio Moises, Rubio Edmundo
Pulmonary and Critical Care, Virginia Tech Carilion School of Medicine, Roanoke, USA.
Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA.
Cureus. 2022 Jul 12;14(7):e26785. doi: 10.7759/cureus.26785. eCollection 2022 Jul.
A twenty-two-year-old woman with a history of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) on rituximab presented with fever, abdominal pain, and worsening shortness of breath requiring supplemental oxygen via nasal cannula one month after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection from which she was minimally symptomatic and had recovered. Radiographic studies revealed bilateral patchy consolidations interspersed with ground-glass opacities (GGO). She was started on antibiotics for presumed community-acquired pneumonia with no improvement. Echocardiography revealed preserved biventricular function and a suspected intracardiac mass. A cardiac magnetic resonance imaging (CMRI) revealed myocarditis and no intracardiac mass. Fever persisted and oxygen requirements increased from FiO2 0.4 to 1.0. Repeat CXR showed subtotal left hemithorax opacification. Bronchoscopic samples showed a negative Gram stain and an unremarkable cell count differential. In view of this and given her lack of response to antibiotics with worsening respiratory status, high-dose steroids were started. She improved rapidly, and six days later she was off oxygen. Transbronchial biopsies showed benign parenchyma with some intra-alveolar fibrin deposition with no definitive evidence of viral cytopathic effect, vasculitis, or diffuse alveolar damage (DAD). Follow-up imaging in the pulmonary clinic revealed improvement of prior airspace disease with some new migratory opacities that completely resolved after 12 weeks. Pulmonary function tests and repeat CMRI were normal three months after discharge. Multisystem inflammatory syndrome in adults (MISA), post-covid organizing pneumonia (OP), and immune reconstitution inflammatory syndrome (IRIS) are rare and potentially steroid-responsive causes of pneumonia, which were in our differential diagnosis. It is imperative to consider the rare possibility of steroid-responsive pneumonia-like MISA, post-COVID-OP, and IRIS in patients with worsening respiratory symptoms following a recent SARS-CoV 2 infection.
一名22岁有儿童自身免疫性神经精神障碍伴链球菌感染（PANDAS）病史且正在接受利妥昔单抗治疗的女性，在感染严重急性呼吸综合征冠状病毒2（SARS-CoV2）后一个月出现发热、腹痛，呼吸急促加重，需要通过鼻导管吸氧，此次感染她症状轻微且已康复。影像学检查显示双侧斑片状实变，其间散在磨玻璃影（GGO）。考虑为社区获得性肺炎，她开始使用抗生素治疗，但病情无改善。超声心动图显示双心室功能正常，疑似心内肿物。心脏磁共振成像（CMRI）显示为心肌炎，无心内肿物。发热持续，氧需求从FiO2 0.4增加到1.0。复查胸部X线显示左半胸大部分致密影。支气管镜检查样本革兰染色阴性，细胞计数分类无异常。鉴于此，且考虑到她对抗生素治疗无反应且呼吸状况恶化，开始使用大剂量类固醇。她迅速好转，6天后不再需要吸氧。经支气管活检显示良性实质，有一些肺泡内纤维蛋白沉积，无病毒细胞病变效应、血管炎或弥漫性肺泡损伤（DAD）的确切证据。肺部门诊的随访影像学检查显示先前的气腔病变有所改善，出现一些新的游走性致密影，12周后完全消失。出院3个月后肺功能测试和复查CMRI均正常。成人多系统炎症综合征（MISA）、新冠后机化性肺炎（OP）和免疫重建炎症综合征（IRIS）是罕见的、可能对类固醇有反应的肺炎病因，均在我们的鉴别诊断范围内。对于近期SARS-CoV 2感染后出现呼吸症状恶化的患者，必须考虑类固醇反应性肺炎样MISA、新冠后OP和IRIS等罕见可能性。
