Tocilizumab in Severe COVID-19 Pneumonia and Concomitant Cyt
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Cytokine release syndrome may cause sudden and potentially life-threatening clinical deterioration in COVID-19 pneumonia, particularly in younger patients. Immunosuppressive therapy may provide important additional therapeutic benefit in these patients. Tocilizumab, a specific IL-6 inhibitor, led to dramatic clinical improvement in a young patient with severe COVID-19-associated cytokine release syndrome.

A 26-year-old, previously healthy man was referred to our emergency department on 28 March with a 5-day history of fever, dyspnoea and cough. He walked into the emergency department independently, but within 1 hour needed an oxygen supply of 15 l/min on an OxyMask to maintain his oxygen saturation at 90%. A pulmonary CT scan showed extensive areas of ground-glass opacities and subtle consolidations bilaterally, predominantly in the basal lung areas, with some extension to all pulmonary lobes (CO-RADS 5). A SARS-Corona E-swab PCR test returned a positive result within a few hours. Laboratory testing showed increased levels of C-reactive protein (CRP; 153 µg/ml), ferritin (703 ng/ml) and D-dimer (3233 ng/ml).

The diagnosis of COVID-19 pneumonia was made and treatment with chloroquine and prophylactic ceftriaxone and low-molecular weight heparin was initiated. The patient was admitted to the intensive care unit for treatment with high-flow oxygen (Optiflow, 30 l; 65% FiO2) resulting in a maximum O2 saturation of 93% and an arterial pO2 of 61.5 mmHg. On the second day of admission, the patient’s respiratory condition further deteriorated and he had to be intubated for invasive ventilation in the prone position. As the extreme clinical deterioration in conjunction with laboratory findings raised a high suspicion of CRS, we decided to administer a single intravenous dose of TCZ at a dose of 8 mg/kg body-weight. TCZ is an IL-6-receptor-blocking biological drug commonly used in the treatment of autoimmune disorders such as rheumatoid arthritis.

Initially, CRP, ferritin, D-dimer and IL-6 levels showed a further increase, suggestive of advancing CRS. However, 2 days after TCZ administration, ventilation conditions improved day-by-day. This was associated with a reversal of laboratory parameters toward normal levels of CRP, ferritin and IL-6 within 5 days of administration of TCZ. During this period, the patient was weaned from mechanical ventilation and successfully extubated. A chest x-ray performed on 5 April, 7 days after treatment with TCZ, showed complete resolution of abnormalities. 9 days after treatment with TCZ, the patient was discharged from hospital without any need for supplemental oxygen.

Conclusively, this case strongly suggests that administration of a single dose of TCZ in advancing SARS-CoV-2-induced CRS (within a hypothesized window of opportunity) contributes to a surprising turnaround in an otherwise damaging clinical course.

Source: https://www.ejcrim.com/index.php/EJCRIM/article/view/1675/2071
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