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A rare presentation of anti-synthetase syndrome requiring intensive care in the midst of a COVID wave.

A 24-year-old female with pneumonia two months prior presented with fever, cough and worsening dyspnea in the midst of a COVID-19 spike. Her initial episode was treated as COVID-19 pneumonia. On presentation, her chest CT was suggestive of bilateral lower zone organizing pneumonia with mild fibrosis and was attributed to post COVID sequelae with an infective exacerbation. Oral steroids and antibiotics were administered following which she had initial improvement and then subsequent deterioration requiring ICU care. A detailed clinical examination (in-person and virtually) at this point revealed the presence of pigmented rashes over the knuckles and weakness of hip muscles. Laboratory work showed elevated creatine kinase levels, positive anti-Ro and anti-Jo1 antibodies which pointed to a diagnosis of anti-synthetase syndrome (ASS). Unique attributes of this case include younger age of presentation in an atypical ethnic group and possibly incited by COVID-19 infection in the peak of a COVID-19 wave. The work-up, diagnosis and initial management of this patient was carried out through a hybrid ICU model which functioned as a traditional ICU in the day and a tele-ICU at night with an appropriate network of sub-specialists including Rheumatologists consulting, thus highlighting a collaborative model in a low resource setting capable of managing rare cases even in the midst of increasing critical care needs during the pandemic.