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Sigman S.A. et al.: A 57-year-old African American man with severe COVID-19 pneumonia... © Am J Case Rep, 2020; 21: e926779 Background Coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The presentation of COVID-19 includes dyspnea, lung edema, and pneumonia. Morbidity and mortality are associated with Acute Respiratory Distress Syndrome (ARDS) and cytokine storm. Hospitalized COVID-19 patients are classified as severe if they require intensive care unit (ICU) admission [1,2]. Here, we report the first case of the use of supportive or adjunctive photobiomodulation therapy (PBMT) in a patient with severe COVID-19 pneumonia. PBMT is an emerging alternative modality with demonstrated anti-inflammatory effects in pain management, lymphedema, wound healing, and musculoskeletal injuries. Additional terms for PBMT include low-level laser (or light) therapy (LLLT), cold laser, and photobiostimulation [3]. The effects of PBMT differ from the thermal effects produced by the high-power lasers used in cosmetic and surgical procedures to destroy the tis- sue [4,5]. PBMT utilizes non-ionizing, non-thermal light sources in the visible and infrared spectra (400–1000 nm) [3]. In PBMT, light is applied over damaged tissues and the light energy ab- sorbed by intracellular chromophores or biomolecules starts a cascade of molecular reactions that improve cell function and enhance the body’s healing process [4]. In effect, light stimu- lates healing, modulates the immune system, and reduces in- flammation, edema, and pain [4]. PBMT is non-invasive, cost- effective, and has no known adverse effects. Empirical use of PBMT in children, adults, and elderly patients with pneumonia, asthma, chronic bronchitis, or pulmonary fi- brosis resulted in reduced chest pain and heaviness, normal- ization of respiratory function, shortened recovery times, and improved immunological and radiological parameters. In these patients, PBMT used in combination with conventional med- ical treatment was safe and appeared to produce a synergis- tic effect in healing [6–10]. Recent publications recommend the use of supportive PBMT in COVID-19 patients [11–13]. ARDS is a critical complication of COVID-19 infection and sup- portive PBMT can ameliorate ARDS and promote lung heal- ing [11,13–18]. Animal models of acute inflammation of the respiratory system suggest that transcutaneous PBMT over the lungs is effective against cytokine storm and ARDS via its anti-inflammatory action at multiple levels [14–18]. The theory of supportive PBMT for COVID-19 is based on la- ser light reaching lung tissue, which relieves inflammation and promotes healing. The World Association for Laser Therapy recommended treatment doses for low-level laser therapy, or PBMT for superficial to deep tissue lesions in musculoskeletal disorders in 2010 [19]. The minimum observed therapeutic dose for a bio-stimulatory effect of red and near-infrared (NIR) lasers is 0.01 J/cm2 [20]. NIR Laser light at a power of 1 W/cm2 projected through bo- vine tissue ranging in thickness from 1.8 to 9.5 cm resulted in effective power densities at 3.4 cm and 6.0 cm [21]. In vet- erinary practice, feline and canine pneumonia is frequent- ly treated with laser doses of 6–10 J/cm2 [22]. These animals have a thicker chest wall and furry skin, making penetration more challenging than in humans. Therefore, the range used in cats and dogs approximates an effective dose for humans. Our previous experience in treating asthma [23] and musculo- skeletal pain and injuries suggested that the anti-inflammato- ry effects of PBMT could benefit the severe inflammatory con- dition in COVID-19 patients. The laser machine used in this case is an US Food and Drug Administration (FDA)-cleared sys- tem for pain management and inflammation reduction in deep joints of the body. The combination of 808 and 905 nm, both NIR wavelengths, provides penetration to depths of 4–5.4 cm. This laser machine is used for deeper tissues like hips and pel- vic joints that are surrounded by thick muscles. The therapeu- tic dose with this machine is 4.5 J/cm2 over the skin to reach these deep targets of the pelvis. Based on our calculations, we used 7.2 J/cm2 over the skin to deliver just over 0.01 J/cm2 of laser energy to the lung. The 7.2 J/cm2 dosage penetrates the chest wall (1.6 to 6 cm in humans) and reaches the lung tis- sue with sufficient energy for bio-stimulation. Scapular pro- traction in the prone position reduces the bone and muscle tissue the laser must penetrate, thereby increasing laser en- ergy to the lung fields. Here, we report the first use of PBMT as a supportive treat- ment in a severe case of COVID-19 pneumonia. Case Report A 57-year-old African American man with a history of hyperten- sion and asthma presented with shortness of breath, severe de- hydration, acute renal failure, and C. difficile-positive diarrhea. A physical examination revealed labored breathing, weakness, and fatigue. Chest X-rays demonstrated worsening bilateral lung infiltrates. Oxygen requirements in the hospital ranged from 2 to 6 L/min oxygen. The patient had been in the ICU for respi- ratory depression with SpO2 of 80% requiring 48 h on 6 L/min oxygen. The diagnosis of SARS-CoV-2 was confirmed for this patient by reverse transcription-polymerase chain reaction by nasopharyngeal swab on an Abbott ID system. Patient con- sent was obtained for an FDA-guided and International Review Board-approved trial of laser treatment for COVID-19 (Lowell General Hospital Federal-wide Assurance number 0001427). The inclusion criteria consisted of a positive COVID-19 test, the ability to self-prone, and requiring at least 1 L/min oxygen. This work is licensed under Creative Common Attribution- NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) 2 Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] APPROVED GALLEY PROOFPDF Image | A COVID-19 Pneumonia Responded to Photobiomodulation Therapy
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