Pulmonary Function and Chest Computed Tomography (CT) Scan Findings After Antifibrotic Treatment for COVID-19-Related Pulmonary Fibrosis

Abstract

BACKGROUND Physicians worldwide have been reporting many cases of COVID-19-induced pulmonary fibrosis. We report the case of a 51-year-old Filipino asthmatic woman who developed post-COVID-19 pulmonary fibrosis subsequently treated with Nintedanib. CASE REPORT The patient presented with a 4-day history of flu-like symptoms in September 2020 and was eventually diagnosed with severe COVID-19 pneumonia. Despite receiving Dexamethasone, Tocilizumab, Remdesivir, and multiple antibiotics, there was increasing oxygen requirement, necessitating ICU admission and high-flow nasal cannula (HFNC). An additional course of hydrocortisone was given due to asthma exacerbation, gradually liberating her from the HFNC. A chest CT scan showed extensive parenchymal changes, for which she received methylprednisolone and physical rehabilitation with persistence of respiratory symptoms. After 40 days of hospitalization, she was sent home on oxygen support and Nintedanib. The patient initially had severe dyspnea (Borg Scale 7) with 6-minute walk distance (6MWD) of 295 meters. Pulmonary function showed moderately severe restrictive lung defect at 52% predicted total lung capacity (TLC) and severely reduced DLCO (28% predicted). Chest CT scoring indicated severe lung involvement. One month after Nintedanib treatment, her Borg Scale improved to 4. Her 6MWD, TLC, and DLCO increased to 434 meters, 64% predicted, and 36% predicted, respectively. A chest CT scan showed regressing fibrosis. After 6 months of treatment, her pulmonary function normalized. DLCO remained moderately reduced (59% predicted) but her 6MWD (457 meters) and CT scan results continued to improve. CONCLUSIONS Nintedanib, along with other interventions, may have potentially improved pulmonary function and CT scan findings in a COVID-19 survivor with pulmonary fibrosis 6 months after treatment.

Figure 1.

Axial sections of the first CT scan dated October 24, 2020 at the level of the aortic arch (A), carinal bifurcation (B), and bronchial bifurcation to middle and right lower lobe branches (C) showing multiple ground-glass opacities with confluences and consolidation (black arrow) and with unsharp demarcations. The focal discrete ground-glass opacities with intralobular septal thickening (white arrow) mostly occupy the periphery of the upper lobes, while the consolidations are noted predominantly in the bilateral lower lobes, with interspersed tubular bronchiectasis. Sub-pleural bands (arrow head) are also seen bilaterally.

Figure 2.

Axial sections of the chest CT scans dated November 20, 2020 taken at the carinal bifurcation (A), bronchial bifurcation to the middle and right lower lobes (B), and lung bases (C). Similar cuts are represented by figures D–F dated May 5, 2021. These images show significant interval decrease in the ground-glass opacities and consolidations (black arrow) in both lungs, with faintly-discernible ill-defined ground-glass densities, thin sub-pleural bands, and multiple fibroses (white arrowhead) in both lungs.