Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Images in Cardiovascular Medicine
Glucocorticoid-Induced Bacterial Endocarditis in COVID-19 Pneumonia ― Something to Be Concerned About? ―
Valentina RegazzoniMarco LoffiAlberto GariniGian Battista Danzi
Author information
JOURNAL OPEN ACCESS FULL-TEXT HTML
Supplementary material

2020 Volume 84 Issue 10 Pages 1887-

Details

A 70-year-old man without any pre-existing valvular heart disease was hospitalized for COVID-19 with bilateral pneumonia. Laboratory tests revealed mild leukocytosis (11,680/mm2) and increased level of C-reactive protein (CRP) (86 mg/L). Arterial blood gas showed a PaO2 of 60 mmHg with SO2 of 89%. Chest CT scan documented extensive ground-glass opacifications in both lungs (Figure A). The patient received high-flow oxygen therapy, intravenous corticosteroid for 5 days (methylprednisolone 40 mg/day) and hydroxychloroquine 400 mg/day. After 10 days of stable clinical condition, he suddenly developed hyperpyrexia (39℃) and confusion. Laboratory tests showed more severe leukocytosis (19,580/mm2; 93% neutrophils), increased levels of CRP (222 mg/L), procalcitonin (5.1 ng/mL), interleukin-6 (19.5 ng/L), fibrinogen (410 mg/dL), and D-dimer (24 μg/mL), and severe thrombocytopenia (19,000/mm2). Cerebral CT scan and MRI documented multiple ischemic areas with hemorrhagic transformation (Figure B,C). Nasopharyngeal swab and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Transesophageal echocardiography demonstrated large vegetations on the aortic valve with severe regurgitation (Figure D, Supplementary Movie), which could have been the cause of the cerebral embolization. Targeted antibiotic therapy was started. Cardiac surgery was delayed.

Figure.

Imaging of a 70-year-old patient with COVID-19 and bilateral pneumonia who relapsed after 10 days of stable condition. Treatment included a glucocorticoid. (A) Chest CT scan showing extensive ground-glass opacifications in both lungs. Cerebral CT scan (B) and MRI (C) show multiple ischemic areas with hemorrhagic transformation, (D) Transesophageal echocardiography revealed large vegetations (arrow) on the aortic valve with severe regurgitation. Cultures were positive for methicillin-sensitive Staphylococcus aureus.

COVID-19 is associated with a severe systemic inflammatory response and, although controversial,1 some recent evidence suggests that corticosteroids may be beneficial in the early acute phase of infection.2 Systemic glucocorticoids have many effects on the immune system that predispose to infection, resulting in a dose-dependent increase in the risk of infection by common bacterial pathogens.3 The underlying disorder and invasive maneuvers during hospitalization further influenced this risk.

In conclusion, the decision to use glucocorticoid therapy for the treatment of COVID-19 pneumonia should be taken cautiously in view of the associated risk of severe bacterial co-infection.

Supplementary Files

Supplementary Movie. Transesophageal echocardiography of a 70-year-old patient with COVID-19 and bilateral pneumonia treated with glucocorticoid who relapsed after 10 days of stable condition. Large vegetations on the aortic valve with severe regurgitation can be seen.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-20-0462

References
 
© 2020 THE JAPANESE CIRCULATION SOCIETY

This article is licensed under a Creative Commons [Attribution-NonCommercial-NoDerivatives 4.0 International] license.
https://creativecommons.org/licenses/by-nc-nd/4.0/
feedback
Top