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Lack of efficacy, and various toxicities due to off-label use: case reportA 73-year-old woman developed Enterococcus faecium infection and bacterial endocarditis during off-label treatment with dexamethasone and tocilizumab for COVID-19 pneumonia. Additionally, she exhibited a lack of efficacy during treatment with meropenem, linezolid and teicoplanin for bacterial endocarditis [routes not stated].The woman was hospitalised with cough, shortness of breath and fatigue in May 2021. Subsequently, her nasopharyngeal swab was positive for severe COVID-19 pneumonia. Her medical history was significant for arterial hypertension, type 2 diabetes mellitus, obesity and coronary heart disease. Later, her chest X-ray demonstrated bilateral pneumonia with ground‑glass opacities. Following admission, she experienced dyspnoea and acute respiratory failure with oxygen saturation of 78%. Her blood test was significant for inflammatory syndrome, and she started receiving remdesivir along with prophylactic enoxaparin sodium [enoxaparin] and off-label treatment with dexamethasone 8mg two times a day and tocilizumab 800mg two times a day for COVID-19 pneumonia. Thereafter, her condition was favourable. However, on day 14, she developed fever (38.5°C) and her condition worsened. Also, her laboratory tests showed elevated procalcitonin level (4.1 ng/mL), liver transaminase levels (AST was 163 U/L and ALT was 120 U/L), troponin (152 ng/mL), D‑dimer (1.78 µg EFU/mL) and decreased estimated glomerular filtration rate (41 ml/min/1.73m 2 ). Subsequently, she developed respiratory distress and required non‑invasive continuous positive airway pressure ventilation. Her pulmonary CT scan showed findings similar to chest radiological findings. Then, her blood culture was positive for Enterococcus faecium. Thereafter, she underwent transthoracic echocardiography, which demonstrated vegetation on the posterior mitral valve leaflet, leading to moderate mitral regurgitation. From the above investigation, she was diagnosed with infective endocarditis. The Enterococcus faecium infection and bacterial endocarditis were attributed to off-label dexamethasone and tocilizumab.The woman was treated with meropenem 1000mg 3 times a day and linezolid 600mg two times a day. Initially, this treatment showed insignificant response. However, following 20 days, she developed thrombocytopenia with platelet count of 58 000/mm 3 . Then, her treatment with linezolid was changed with teicoplanin 12 mg/kg twice a day as loading dose and 12 mg/kg daily as a maintenance dose. Despite of this treatment, she developed multiple organ failure and died due to it on day 25 of the admission.
Lack of efficacy, and various toxicities due to off-label use: case reportA 73-year-old woman developed Enterococcus faecium infection and bacterial endocarditis during off-label treatment with dexamethasone and tocilizumab for COVID-19 pneumonia. Additionally, she exhibited a lack of efficacy during treatment with meropenem, linezolid and teicoplanin for bacterial endocarditis [routes not stated].The woman was hospitalised with cough, shortness of breath and fatigue in May 2021. Subsequently, her nasopharyngeal swab was positive for severe COVID-19 pneumonia. Her medical history was significant for arterial hypertension, type 2 diabetes mellitus, obesity and coronary heart disease. Later, her chest X-ray demonstrated bilateral pneumonia with ground‑glass opacities. Following admission, she experienced dyspnoea and acute respiratory failure with oxygen saturation of 78%. Her blood test was significant for inflammatory syndrome, and she started receiving remdesivir along with prophylactic enoxaparin sodium [enoxaparin] and off-label treatment with dexamethasone 8mg two times a day and tocilizumab 800mg two times a day for COVID-19 pneumonia. Thereafter, her condition was favourable. However, on day 14, she developed fever (38.5°C) and her condition worsened. Also, her laboratory tests showed elevated procalcitonin level (4.1 ng/mL), liver transaminase levels (AST was 163 U/L and ALT was 120 U/L), troponin (152 ng/mL), D‑dimer (1.78 µg EFU/mL) and decreased estimated glomerular filtration rate (41 ml/min/1.73m 2 ). Subsequently, she developed respiratory distress and required non‑invasive continuous positive airway pressure ventilation. Her pulmonary CT scan showed findings similar to chest radiological findings. Then, her blood culture was positive for Enterococcus faecium. Thereafter, she underwent transthoracic echocardiography, which demonstrated vegetation on the posterior mitral valve leaflet, leading to moderate mitral regurgitation. From the above investigation, she was diagnosed with infective endocarditis. The Enterococcus faecium infection and bacterial endocarditis were attributed to off-label dexamethasone and tocilizumab.The woman was treated with meropenem 1000mg 3 times a day and linezolid 600mg two times a day. Initially, this treatment showed insignificant response. However, following 20 days, she developed thrombocytopenia with platelet count of 58 000/mm 3 . Then, her treatment with linezolid was changed with teicoplanin 12 mg/kg twice a day as loading dose and 12 mg/kg daily as a maintenance dose. Despite of this treatment, she developed multiple organ failure and died due to it on day 25 of the admission.
Infective endocarditis in the context of Coronavirus disease (COVID-19) is an emerging clinical entity. If not identified timeously it is associated with high morbidity and mortality. Herein, we provide an overview of literature supported by a clinical vignette, and highlight the importance of early recognition and management of IE in the context of COVID-19 infection.
Background Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic, leading to significant morbidity and mortality. The interplay between COVID-19 and other medical conditions can complicate diagnosis and management, necessitating further exploration. Case presentation This case report presents a patient with COVID-19 who developed infective endocarditis (IE) and mitral valve perforation caused by methicillin-resistant Staphylococcus aureus on a native mitral valve. Notably, the patient did not exhibit typical IE risk factors, such as intravenous drug use. However, he did possess risk factors for bacteremia, including a history of diabetes mellitus and recent steroid use due to the COVID-19 infection. The diagnosis of IE was crucially facilitated by transesophageal echocardiography. Conclusions This case highlights the potential association between COVID-19 and the development of infective endocarditis. Prompt evaluation using transesophageal echocardiography is vital when there is a high suspicion of IE in COVID-19 patients. Further research is required to elucidate the precise relationship between COVID-19 and IE.
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