This is the case of a 77-year-old man with hypertension, emphysema, and old tuberculosis, who is an ex-smoker and who presented with fever and sore throat. Levofloxacin and ciclesonide were administered on day 8 for bilateral pneumonia with respiratory failure. He was diagnosed with COVID-19 on day 10. He needed IMV due to a rapid progressive respiratory failure on day 11. P/F was 170, which was classified as moderate ARDS at that time. Although favipiravir has been initiated, low-dose steroid (hydrocortisone 250mg/day), intravenous immunoglobulin, sivelestat, and prone position therapy were administered after intubation. The respiratory status improved temporarily, but P/F and consolidation with traction bronchiectasis and volume loss worsened. MP (methyl-prednisolone 1000mg for three days) was initiated from day 14. After this therapy, P/F, LDH, and CT findings were improved (Fig. 1). PSL 30mg (0.5mg/kg/day) was started after the pulse therapy, and the dose was gradually tapered. He was successfully extubated on day 30, negative conversion of RT-PCR was confirmed on day 24, and finally he was discharged without oxygen demand on day 30. PSL was finished on day 33.
MP with respiratory failure due to COVID-19 was administered to four patients (three males, one female). The median day of MP administration was day 17 (14-29), the late phase of COVID-19. The median age was 64.5 years (43-77). The comorbidities were hypertension in three cases, history of smoking in two cases, and bronchial asthma, emphysema, and old pulmonary tuberculosis in one case. The median time to diagnosis, respiratory failure, or intubation was 10.5 days (6-11), 9.5 days (8-12), or 12 days (10-23), respectively. The median findings of body temperature, lymphocyte, LDH, and C-reactive protein on intubation were 38.5  Celsius (36.8-38.6), 393.5/mul (219-1227), 442.5IU/l (364-599), and 15.7mg/dl (12.8-35.8), respectively. Lopinavir/ritonavir, hydroxychloroquine, favipiravir, and ciclesonide which were expected to have an antiviral effect were administered on day 10.5 (8-19) (median, range). Intravenous immunoglobulin and antibiotics were administered in all cases. Prone position therapy was performed in three cases. Low-dose corticosteroids were administered in all cases around the timing of intubation. MP improved P/F, LDH, and CT findings in all cases in spite of bimodal worseness after intubation (Figs. 1 and 2). The median duration of systemic corticosteroid, intubation, ICU stay, and negative conversion of RT-PCR was 26 days (13-37), 9.5 days (8-12), 11 days (9-17), and 35 days (24-51), respectively. All cases succeeded in withdrawing from oxygen therapy, but one patient was transferred to a rehabilitation hospital due to disuse symptom. No other adverse events were observed.
Computed tomography of the chest during the clinical course in case 1. It showed bilateral peripheral ground glass opacities on day 11 (on admission). These opacities progressed consolidation with traction bronchiectasis and volume loss on day 19 (the day steroid pulse therapy was started). Patient almost recovered from these findings on day 61.