- Question: Tocilizumab in COVID-19 Patient with Acute Respiratory Distress Syndrome and...
NEJM Resident 360 ? Discussion
Covid-19 Case Reports
Tariq Kewan, Dr
Tocilizumab in COVID-19 Patient with Acute Respiratory Distress Syndrome and Cytokine Release Syndrome
Tariq Kewan, MD and Bassel Akbik, MD
Critical Care Department, Cleveland Clinic Foundation.
Date of presentation: 03/18/2020
Case Presentation
An 80 year-old male with past medical history of coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, and chronic kidney disease presented with sore throat, fever, productive cough and general fatigue. He denied any recent travel history or sick people contact.
Physical Exam
In the emergency department patient was tachycardiac , tachypneic, febrile (38.6 C) and hypoxic on room air. Chest exam was positive for bilateral crackles and wheeze.
Pertinent Laboratory values
White blood cell count was normal (4.87) and absolute lymphocyte count was low at (.5 k/uL) . Sepsis lactate was negative. Respiratory sputum culture didn’t grow any specific microorganisms. Streptococcus pneumonia and legionella antigens were negative. Assays to detect influenza viruses and a respiratory syncytial virus were all negative. A nasopharyngeal swab was positive for SARS-CoV-2 on real-time reverse transcription polymerase chain reaction (RT-PCR) assays. Triglyceride level was 185 mg/dl and interleukin 6 level was 14 pg/ml. Blood culture drawn at the date of admission came back negative.
Pertinent images
Chest X ray at the time of admission revealed new hazy right upper lobe lateral opacity and early lobar pneumonia. Chest X-ray after treatment showed mild interstitial prominent with significant improvement (figure-1).
Treatment and Outcomes
Patient was admitted to regular medical floor and started on azithromycin and hydroxychloroquine for total of 5 days. He was initially on 4 L NCL. After 2 days of admission his clinical condition deteriorated and he required ICU admission. He was intubated and started on phenylephrine and vasopressin for circulatory shock. He was diagnosed with cytokine release storm and was given one dose of 400 mg tocilizumab and methyl prednisone 60 mg daily for 6 days. After 2 days of tocilizumab, he was weaned off all pressors. Also, his CRP and ferritin dropped from 21.3 mg/dl and >100,000 ng/dl on day of ICU admission to 17.9 mg/dl and 1793 ng/dl after 2 days respectively. He was extubated after 12 days of tocilizumab treatment and transferred to regular medical floor on 4 L NCL.
Lessons Learned
Cytokine release storm (CRS) in patient with COVID-19 is critical and can take place very rapidly after COVID-19 diagnosis. Tocilizumab is a monoclonal antibody against IL-6 that can be used in COVID-19 ARDS patients with CRS. Tocilizumab can improve oxygenation and hemodynamic stability in COVID-19 patient with CRS.
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7 Comments
0 Answers
- Krista Nottage, MBBSPatient's presenting vitals and current status
Thank you for this case Dr. Kewan. Please could you tell/ update us on whether the patient has since been discharged or if he remains stable on the ward? I am also interested to know the values of his presenting vitals if possible: what was his Sp02 on presentation?The heart rate and respiratory rates? Thank you again!
on Apr 6
- Jacqui Horwitz, MBASimilar Case in Italy
Today Medscape published a case of a physician in Italy who was treated with Tocilizumab and recovered: medscape.com/viewarticle/92815...
I hope this gets some attention.
Doctor With COVID-19 Recovering After Treatment, 'Lot of Luck'
Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center. Dr Alberto Bassi, a 62-year-old Italian dermatologist, was still hospitalized in the town of Cas... Read More
1
on Apr 6
- Tariq Kewan, Dr
Patient is still in the regular floor. VS on the day of admission: Temp: 38.1, HR: 114, RR:18, BP: 120/62 and SPO2: 93% on 2 L NCL.
on Apr 6
- Stanford, CA
- Stanford University School of Medicine
Sean Wu, MD PhDRecovery parameters
Thanks for the interesting case. The drop in CRP you report is similar to the pre-print Xu et al chinarxiv paper on 21 pts treated w toci. Since the inflammatory markers were improving, what was slow to recover (e.g. lung infiltrate/O2 req, vital signs, etc) that required 10 additional days of vent?
Thursday at 1:15pm- Tariq Kewan, Dr
Oxygenation takes long time to recover, Hemodynamics recovered totally after 2 days. Keep in mind the effect of sedation and high PEEP on MAP.
1
Thursday at 1:50pm
- Athens, Attiki
- ICU Dept, Sotiria Athens Hospital of Chest Diseases
Anna Kyriakoudi, Dr
I would like to ask: How the cytokine storm was define? Did you measure IL-6? Can you provide the values of IL-6?
Saturday at 5:47am- Tariq Kewan, Dr
IL 6 was 119 of/ml
Saturday at 10:26pm
