LAUSR

INTRODUCTION: Acute macroglossia has been seen in cases of bradykinin mediated angioedema, trauma, or in cases of depositional diseases such as amyloidosis We report three cases of patients with confirmed SARS-CoV-2 (COVID-19) disease who developed macroglossia after admission to the intensive care unit (ICU) for mechanical ventilation All three patients received remdesivir, pronation therapy, inhaled nitric oxide, cisatracurium, and chlorhexidine gluconate oral rinses METHODS: The first patient was a 49-year-old male with no significant past medical history who was mechanically ventilated on hospital day 1 and received dexamethasone as well as convalescent plasma He developed macroglossia with labial swelling on day 9 following ceftriaxone administration Improvement was noted after administration of diphenhydramine, montelukast, famotidine, and an increase in his dexamethasone dose The second patient was a 57-year-old female with a history of morbid obesity and asthma who was mechanically ventilated on hospital day 2 and received dexamethasone Macroglossia developed on day 11 following micafungin administration, with improvement after dexamethasone and diphenhydramine administration The third patient was a 46-year-old female with a history of obesity, diabetes, and asthma who was placed on mechanical ventilation hospital day 1 and received tocilizumab Macroglossia developed between day 4 and day 8, with improvement over several weeks without directed intervention RESULTS: Macroglossia is a relatively rare finding in the ICU Although therapies such as pronation and endotracheal intubation are possible etiologies, these are often done in ICU with the incidence of macroglossia remaining relatively low Each of these patients received Remdesivir within 24 hours prior to the onset of macroglossia Given this is a newer medication that is being widely used, we propose this as a potential side effect Alternatively, COVID-19 itself could be a cause The presence of microthrombi and inflammation have been well described in other organ capillaries, and ACE2 receptors have been identified on tongue epithelium Clinically, macroglossia can impact the safety of extubation for patients on mechanical ventilation and is an important finding when treating critically ill patients with COVID