Compassionate Use of Remdesivir for Patients with Severe Covid-19

BACKGROUND

Remdesivir, a nucleotide analogue prodrug that inhibits viral RNA polymerases, has shown in vitro activity against SARS-CoV-2.

METHODS

We provided remdesivir on a compassionate-use basis to patients hospitalized with Covid-19, the illness caused by infection with SARS-CoV-2. Patients were those with confirmed SARS-CoV-2 infection who had an oxygen saturation of 94% or less while they were breathing ambient air or who were receiving oxygen support. Patients received a 10-day course of remdesivir, consisting of 200 mg administered intravenously on day 1, followed by 100 mg daily for the remaining 9 days of treatment. This report is based on data from patients who received remdesivir during the period from January 25, 2020, through March 7, 2020, and have clinical data for at least 1 subsequent day.

RESULTS

Of the 61 patients who received at least one dose of remdesivir, data from 8 could not be analyzed (including 7 patients with no post-treatment data and 1 with a dosing error). Of the 53 patients whose data were analyzed, 22 were in the United States, 22 in Europe or Canada, and 9 in Japan. At baseline, 30 patients (57%) were receiving mechanical ventilation and 4 (8%) were receiving extracorporeal membrane oxygenation. During a median follow-up of 18 days, 36 patients (68%) had an improvement in oxygen-support class, including 17 of 30 patients (57%) receiving mechanical ventilation who were extubated. A total of 25 patients (47%) were discharged, and 7 patients (13%) died; mortality was 18% (6 of 34) among patients receiving invasive ventilation and 5% (1 of 19) among those not receiving invasive ventilation.

CONCLUSIONS

In this cohort of patients hospitalized for severe Covid-19 who were treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 patients (68%). Measurement of efficacy will require ongoing randomized, placebo-controlled trials of remdesivir therapy. (Funded by Gilead Sciences.).

A Patient With Hemoptysis and the Sign of the Camalote

A 30-year-old woman presenting with hemoptysis followed by acute respiratory distress developed a diagnostic pulmonary radiographic finding, called the sign of the camalote, indicative of ruptured hydatid cyst. Her computed tomography scan demonstrated the characteristic detached parasitic membrane floating on cystic fluid, reminiscent of Amazonian camalote leaves. She was managed successfully surgically. Ruptured hydatid cysts may present as a diagnostic challenge, in which the sign of the camalote may provide an important clue for this serious complication.

The role of extracorporeal membrane oxygenation in severe pulmonary coccidioidomycosis

BACKGROUND

Severe coccidioidal pneumonia with acute respiratory distress syndrome (ARDS) is associated with high mortality. Extracorporeal membrane oxygenation (ECMO) has been applied successfully to other severe fungal pneumonia associated with ARDS. We review our experience with the use of ECMO in severe coccidioidal ARDS.

OBJECTIVES

To review indications and outcome of ECMO in severe pulmonary coccidioidomycosis.

METHODS

Three cases of severe ARDS caused by coccidioidomycosis are presented. All were managed with ECMO. Clinical course, complications, antifungal therapy and outcome are reviewed.

RESULTS

Three cases of severe coccidioidal ARDS survived after treatment with ECMO. Common complications included bacterial pneumonia, encephalopathy and critical illness myopathy. They received liposomal amphotericin during ECMO, and transitioned to azole therapy. All required prolonged hospitalization and rehabilitation.

CONCLUSIONS

ECMO was life-saving in cases of coccidioidal ARDS. Common complications included pneumonia, encephalopathy and critical illness myopathy. All cases were successfully managed with liposomal amphotericin followed by azole therapy. They required prolonged hospitalization and rehabilitation.

Unexplained hypotension in Hodgkin's disease

A 51-year-old black male with progressive polymyositis presented to our hospital with respiratory failure. Hemodynamic monitoring revealed tachycardia, arterial hypotension, a high cardiac index, and low systemic vascular resistance. Evaluation for common etiologies of this hemodynamic pattern was unrewarding. He was found to have Hodgkin's disease of the bone marrow. Aggressive combination chemotherapy led to normalization of heart rate and arterial pressure. It is postulated that Hodgkin's disease through some undetermined mechanism can cause a hyperdynamic circulatory pattern. This hemodynamic state reversed with suppression of the tumor.