Post-Covid Organizing Pneumonia

A myriad of acute clinicopathological effects of novel SARS Coronavirus 2 (SARS-Cov-2) infection are being described. Here, we present a case report which illustrates a biopsy proven distinct chronic complication of Covid-19 disease which afflicts some survivors: Post Covid-19 Organizing Pneumonia (PCOP). A 30 year old African-American female with known Human Immunodeficiency Virus (HIV) infection on anti-retroviral therapy (ART) and recently diagnosed nodular marginal zone lymphoma, on chemotherapy, became infected with SARS-Cov-2 in early August, 2020. She presented with fever, increased cough, and shortness of breath worsening over two weeks. In the emergency room, she had temperature 102o F, heart rate of 110 with oxygen saturation 88% on room air. Lab work was significant for Leukocytosis of 17.62 k/uL and recent absolute CD4 of 590/mm3. SARSCoV-2 Polymerase Chain Reaction (PCR) test was positive. Admission Chest Roentgenogram (X-ray) revealed bilateral basal opacities consistent with Covid-19 Pneumonia. Our patient was admitted and received Dexamethasone and a course of empiric antibiotics for community acquired pneumonia. She was discharged on brief oral prednisone taper with home oxygen 2L/min;However, she would be readmitted to hospital twice more over the next eight weeks with similar complaints of cough, recurrent fever, and dyspnea with new focal opacities on serial chest imaging (Figure 1). Her symptoms persisted despite broadened empiric antibiotics including antifungal therapy. Extensive lab work-up for secondary infection and autoimmune disease was unrevealing. Bronchoscopy was finally done with Transbronchial Cryobiopsy (TBC) revealing acute and chronic inflammation with interstitial fibrosis. Bronchoalveolar lavage (BAL) cultures were negative. As evidenced by serial imaging (Figure 1), our patient consistently improved with empiric steroids for organizing pneumonia. Her clinical findings recurred with attempts to taper steroids even at five months post initial positive SARS-CoV-2 PCR. This case illustrates Post Covid-19 Organizing Pneumonia (PCOP). It is a Clinicopathologic syndrome characterized by rapid resolution with corticosteroids, but frequent relapses when treatment is tapered or stopped.1 It also illustrates several salient issues in caring for patients who survive acute SARS-CoV-2 infection: i) Delayed viral clearance related to chronic immunosuppression,2 ii) Delayed Bronchoscopy in an effort to mitigate infection risk to care providers, iii) The impact of ongoing therapy on consequent delayed pathology findings,3 iv) Increased morbidity associated with both late disease recognition and our attempts to taper chronic steroid therapy in the setting of an Organizing Pneumonia4 and v) The possibility that earlier biopsy, diagnosis and uninterrupted therapy may prevent pulmonary fibrosis.