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Coronavirus disease 2019 (COVID-19) has spread to more than 70 countries around the world since its discovery in 2019. More than 2.5 million cases and more than 130,000 deaths have been reported in the United States alone. The common radiological presentation in this disease is noted to be the presence of ground glass opacities and/or consolidations. We report a case of 40-year-old male admitted for COVID-19 and rapidly deteriorated into severe acute respiratory distress syndrome requiring intubation and mechanical ventilation with no prior history of smoking or lung disease. The patient had normal imaging 3 days prior to admission to the hospital and rapidly developed a large pneumatocele with pneumothorax requiring chest tube placement that later on resolved. This is a unique radiologic finding in COVID-19 and likely related to severe inflammation secondary to SARS-CoV-2 infection.

Pulmonary fibrosis (PF) is characterized by excessive deposition of extracellular matrix components and destruction of the pulmonary parenchyma. Studies have shown severe Coronavirus Disease 2019 can lead to PF with residual lung function abnormalities and fibrotic remodeling. As of today, there is no consensus on treatment for PF caused by COVID-19. We are reporting a case series of three post-COVID-19 PF patients treated with tapering prednisone. Case Series:Patient 1 is 52-year-old male presented to the clinic after a 3-month hospital course of COVID-19 requiring hyperbaric hood. He was discharged with 2L of home oxygen. The patient saturated at 95% at rest but desaturated to 70% on exertion. Chest X-ray (CXR) and CT thorax showed diffuse ground glass opacity with pulmonary fibrosis and scarring. Tapering prednisone from 40mg over 1 month was initiated. Follow-up visit after one month confirmed reduce home oxygen requirement. CXR also revealed mild improvement in interstitial infiltrates. Patient 2 is a 56-year-old male hospitalized 2 months ago for COVID-19 where he required non-rebreather mask for oxygen supply. In the office, he complained of shortness of breath on exertion. CXR showed diffuse bilateral airspace opacities and thickened interstitial lung markings. Pulmonary function test (PFT) revealed moderate restrictive pattern with reduced lung volumes. He was sent home with a course of tapering prednisone over 1 month and weekly office follow up. His symptoms improved. Repeat CXR showed improving bilateral diffuse reticular markings. Repeat PFT improved to mild restrictive lung pattern. Patient 3 is a 70-year-old male hospitalized for 1 moth for COVID-19 requiring face mask with recent discharge on 4L home oxygen. After 2 weeks of hospital discharge, the patient still required 2L of oxygen at home. CXR showed streaky lung opacities predominantly in the left lower lung field. The patient was started on tapering prednisone. At 2-month follow-up, he admitted clinical improvement of symptoms and was able to titrate off home oxygen at rest. Repeat CXR also showed improvement of streaky opacity in the left mid/lower lung. Discussion:No evidence-based treatment is available for post-COVID-19 PF. Corticosteroid is used for treatment of acute exacerbation of other forms of PF by decreasing inflammation in the lungs, and therefore may improve symptoms of post-COVID-19 PF. Our patients received 1-month course of tapering prednisone treatment showed mild clinical improvement with no major adverse effect. Further clinical trials should address the utility and risks of corticosteroid in post-COVID-19 PF.

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Introduction. Cytomegalovirus (CMV) is a common double-stranded DNA (dsDNA) virus affecting a large majority of the world’s population. In immunocompetent patients, CMV infection can range anywhere from an asymptomatic course to mononucleosis. However, in the immunocompromised patient, prognosis can be deadly as CMV can disseminate to the retina, liver, lungs, heart, and GI tract. We present a case of CMV pancreatitis afflicting an immunocompromised patient. Case Summary. A 45-year-old Hispanic female with no past medical history presented to the emergency department (ED) for three days of abdominal pain associated with nausea, vomiting, and diarrhea. ED vitals showed a sepsis picture with fever, tachycardia, low white blood cell (WBC) count with bandemia, and CT scan showing acute pancreatitis, cholelithiasis, gastritis, and colitis. The patient denied alcohol use and MRCP showed no stone impaction. Sepsis protocolled was initiated for biliary pancreatitis, and the patient was admitted to the medicine floors with appropriate consulting services. Over the course of admission, the patient responded poorly to treatment and had a steady decline in respiratory status. She tested positive for HIV with a severely depressed CD4 count (42 cells/McL) and high viral load (1,492,761 copies/ml) and started on appropriate prophylactic antibiotics and HAART therapy. The patient was moved to the Medical Intensive Care Unit (MICU) after acute respiratory failure secondary to ARDS requiring mechanical ventilation with initiation of ARDS protocol. The patient was hemodynamically unstable and required vasopressor support. Hospital course was complicated by melena which prompted an esophagogastroduodenostomy (EGD) with biopsy yielding CMV gastritis. Serum CMV viral load was also found to be positive along with an elevated lipase level, indicative of pancreatitis. Despite initiation of ganciclovir, the patient continued to have refractory hypoxia despite full ventilatory support and proning. Unfortunately, the patient was deemed too unstable for transfer to an ECMO facility. She eventually succumbed to respiratory failure. Discussion. CMV is a Herpesviridae virus that is prevalent among more than half of the world’s population. Its effects range from no presenting symptoms to respiratory failure depending on immune status. CMV more commonly affects the retina, lungs, liver, and GI tract; however, in rare cases, it is known to affect the pancreas as well. Other more common causes of pancreatitis were ruled out during the progression of this patient, and an elevated lipase with high CMV viral load points towards CMV pancreatitis. Conclusion. This is one of only a few reported cases of CMV pancreatitis and warrants further study due to the massive prevalence of CMV in the entire world’s population. Our case demonstrates the extent of dissemination of CMV in a severely immunocompromised patient by showing clear cut pancreatitis secondary to said viral infection with exclusion of other possible causes. Our hope is that clinicians will change their practice to include a more scrutinized study into causes of pancreatitis especially in their immunocompromised patients.