Enoxaparin sodium/methylprednisolone
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Enoxaparin sodium/methylprednisolone Cytomegalovirus reactivation, gastrointestinal haemorrhage and off-label use: case report
A 73-year-old man developed cytomegalovirus (CMV) reactivation during off-label treatment with methylprednisolone for COVID-19 pneumonia, and GI bleeding during treatment with enoxaparin sodium [routes not stated; not all indications and dosages stated]. The man presented with fever, dry cough and worsening dyspnoea. His medical history was significant for type II diabetes mellitus, hypertension, atrial fibrillation, multivessel coronary artery disease and underwent repeated percutaneous angioplasty with stenting two years prior. He was diagnosed with primary cutaneous large B-cell lymphoma leg type and had received local radiotherapy 2 months prior. Based on the clinical, imaging and PCR analysis, the diagnosis of COVID-19 pneumonia was made. An ECG showed atrial fibrillation. He was initiated on high-flow oxygen and continuous positive airways pressure (CPAP). His blood findings were significant for leucocytosis, neutrophilia and marked lymphocytopenia. He started receiving off-label hydroxychloroquine 400mg two times a day for first 24 hours (loading dose) followed by 200mg two times a day, lopinavir/ritonavir 100/25mg two times a day and methylprednisolone 80 mg/day (1 mg/kg), which was further tapered. He also started receiving enoxaparin sodium [enoxaparin]. He received antiviral treatment along with methylprednisolone for 10 days, when his respiratory failure gradually improved and he was weaned off from CPAP. Subsequently, on day 18, he developed melaena, epigastric pain, hypotension, tachycardia, GI bleeding along with a drop in Hb levels. The man was treated with IV fluids and received transfusions of two units of RBCs. Further endoscopy showed multiple large and confluent ulcers in the first and second portions of the duodenum indicating CMV duodenitis. Further, duodenal ulcer biopsy, serological test (IgG and IgM positivity) and CMV immunohistochemistry confirmed CMV reactivation. His CMV reactivation was attributed to methylprednisolone, and GI bleeding was attributed to enoxaparin sodium. His treatment with enoxaparin sodium [enoxaparin] was stopped, and he was treated with ganciclovir. Abdominal CT scan revealed pancreatitis with a non-homogeneous pattern of the pancreatic head and peripancreatic fluid collection. A slight elevation of pancreatic amylase and lipase were noted. Subsequently, the abdominal pain subsided and pancreatic enzymes returned to normal. The CMV-DNA titer dropped significantly on day 12 following ganciclovir initiation. Eventually, he was discharged on day 43. Marchi G, et al. Cytomegalovirus-Induced Gastrointestinal Bleeding and Pancreatitis Complicating Severe Covid-19 Pneumonia: A Paradigmatic Case. Mediterranean Journal 803515477 of Hematology and Infectious Diseases 12: No. 1, 2020. Available from: URL: http://doi.org/10.4084/MJHID.2020.060
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