1 INTRODUCTION
According to the World Health Organization (WHO), viral diseases are emerging as a serious public health issue worldwide. In the last two decades, many viral epidemics such as severe acute respiratory syndrome coronavirus (SARS-CoV) disease from 2002 till 2003, and hemagglutinin type 1 and neuraminidase type 1 (H1N1) influenza in 2009, have been reported. Most recently, SARS-CoV2 was detected for the first time in Wuhan, China, in December 2019. On February 11, 2020, the WHO named this disease, coronavirus disease 2019 (COVID-19). This new virus is highly contagious and has rapidly spread globally. On January 30, 2020, the outbreak was declared a Public Health Emergency of International Concern (PHEIC) by the WHO. On March 11, 2020, as the number of COVID-19 cases outside China increased 13 times and more than 114 countries were involved, the WHO declared the COVID-19 a pandemic.1To date (December 26, 2020), Pakistan has 469,482 confirmed cases of COVID-19 with a total death toll of 9816.2 The majority of the patients with COVID-19 have an uneventful recovery. However, approximately 19% of the patients suffer from a progressive worsening of the disease leading to severe pneumonia in 14% and critical pneumonia in 5% of the patients, which leads to acute respiratory distress syndrome (ARDS).3 Multiple therapeutic agents are being used and tried across the world for COVID-19 treatment and the management of its symptoms and complications.4
Immune-mediated response from the host of COVID-19 can lead to cytokine storm that leads to enormous vascular inflammation, disseminated coagulation, and shock, leading to multi-organ failure and death. This inflammatory pathophysiology has led to the use of corticosteroids in COVID-19 management.3 Since corticosteroids cause immune suppression by impairing the innate immunity, their use has largely been discouraged due to the fear of worsening of viral propagation.5 The majority of the earlier studies involving the use of steroids in SARS-CoV disease and the Middle East respiratory syndrome coronavirus (MERS-CoV) disease showed adverse outcomes.6,7 The WHO and the Center for Disease Control and Prevention (CDC) specifically advised against the use of corticosteroids in COVID-19 management earlier in the pandemic.3 The recent RECOVERY trial has shown significantly improved outcomes with dexamethasone, in severe COVID-19 patients who required oxygen therapy or were on a mechanical ventilator.8 Initially, we did not use steroids for COVID-19 management at our center as per the earlier WHO and CDC recommendations. However, subsequently, steroids became part of our COVID-19 management protocol based on the emerging evidence as well as our national clinical management guidelines for COVID-19 infection.2 In this study, we retrospectively compared the outcome of COVID-19 patients (recovery versus mortality) who were treated with steroids with those who were not treated with steroids during their course of hospital stay.