How to follow-up a patient who received tocilizumab in severe COVID-19: a case report
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European Journal of Medical Research Open Access
CASE REPORT
How to follow‑up a patient who received tocilizumab in severe COVID‑19: a case report Regina B. Podlasin1, Justyna D. Kowalska2* , Andrzej Pihowicz3, Beata Wojtycha‑Kwaśnica4, Magdalena Thompson1, Tomasz Dyda5, Hanna Czeszko‑Paprocka6 and Andrzej Horban2
Abstract Background: COVID-19 is characterized by fast deterioration in the mechanism of cytokine storm. Therefore, treat‑ ment with immunomodulating agents should be initiated as soon as hyperinflammation is established. Evidence for the use of tocilizumab (TCZ) in COVID-19 is emerging, but the drug in this setting is used “off label” with limited data on both effectiveness and safety. Therefore, Hospital for Infectious Diseases in Warsaw established a Standard Operat‑ ing Procedure (SOP) for the use of TCZ in severe COVID-19 cases. Case presentation: Here, we present a case of 27-year-old, otherwise healthy man, who was successfully treated with chloroquine, azithromycin, tocilizumab and a standard of care. Initially the magnitude of lung devastation, clini‑ cal deterioration and the need for mechanical ventilation suggested unfavorable prognosis. However, we observed complete regression in radiological changes and rapid clinical improvement. Irrespective of this, patient’s serum interleukin 6 and aminotransferases remained elevated even after a month from treatment. Conclusions: An overlapping effect of hyperinflammation, hypoxic organ injury and drug-related toxicity warrants a long-term follow-up for COVID-19 survivors. In addition, residual IL-6 receptors blockage may mask new infections. A standardized approach to follow-up for COVID-19 survivors is urgently needed. Current and future research should also investigate the impact of experimental therapies on lung tissue healing and regeneration, as well as long-term treatment toxicities. Keywords: SARS-CoV-2, COVID-19, Tocilizumab, Chloroquine, ARDS, Cytokine storm Background In the course of SARS-CoV-2, most infections are mild or asymptomatic, but up to 25% of hospitalized patients would experience severe complications and progress to critical condition characterized by acute respiratory distress syndrome (ARDS), requiring mechanical ventilation [1]. In the course of Coronavirus Disease 2019 (COVID19) pathogenic T cells and inflammatory monocytes may enter the pulmonary circulation and initiate the inflammatory storm leading to lung injury and immune *Correspondence: [email protected] 2 Department of Adults’ Infectious Diseases, Medical University of Warsaw, Warsaw, Poland Full list of author information is available at the end of the article
disorder in severe COVID-19 patients [2]. Zhang et al. discussed that the sIL-6R (soluble receptor) and mIL6R (membrane receptor) blockage with tocilizumab used in COVID-19-related cytokine release syndrome may reduce the mortality [3]. This has been confirmed by several retrospective cohort studies and case series from China and Europe [4–10]. The Polish Association of Epidemiologists and Infectio
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