We report a Russian case of a 61-year-old male patient with confirmed COVID-19 infection who developed nosocomial pneumonia complicated by lung abscess associated with multi-drug-resistant isolates of Klebsiella pneumoniae and Acinetobacter baumannii, which could have been provoked due to the immunosuppressive therapy. We discuss the existing literature highlighting the issue of the prudent balance between benefits and risks when prescribing immunomodulators to hospitalized patients with COVID-19 due to the risk of difficult-to-treat nosocomial infections caused by MDR Gram-negative bacterial pathogens. Currently, there is evidence of a substantial positive effect of dexamethasone on the course of COVID-19 in patients requiring supplemental oxygen or anti-interleukin-6 drugs in individuals with prominent systemic inflammation. However, it seems that in real clinical practice, the proposed criteria for initiating treatment with immunomodulators are interpreted arbitrarily, and the doses of dexamethasone can significantly exceed those recommended.

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Background: Pulmonary manifestations and lung impairment are rarely associated with the adult Still's disease and are reported in less than 5%. Case presentation: The present clinical case describes the adult Still's disease with pulmonary involvement in a 45- year-old male. The main clinical manifestations included continuous fever, failure to respond to antibiotic therapy, skin rashes, musculoskeletal syndrome and pharyngitis. Bronchopulmonary lymphadenopathy, interstitial changes and dense foci with clear contours were detected in the lungs. Laboratory abnormalities included neutrophilic leukocytosis, increased ALT, AST, and elevated serum inflammatory marker levels. The disease was characterised by a cyclical course with strictly defined time intervals between flare-ups and remissions. After the prescription of methylprednisolone with the subsequent addition of methotrexate, a complete regression of clinical symptoms, normalization of laboratory tests, and partial regression of computed tomography findings in the lungs were observed. Conclusions: Pulmonary involvement, despite the low incidence, is an unfavorable manifestation of adult Still's disease. An individual feature of this case report was the asymptomatic lung involvement manifested only by changes revealed by computed tomography. For a long time, flare-ups of the disease were considered as a bacterial infection of unclear nature requiring systemic antibiotics.