Tocilizumab
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Decrease in WBC count following an off-label use: case report A 38-year-old man developed decrease in WBC count following an off-label use of tocilizumab, indicated for COVID-19 pneumonia and acute pancreatitis. The man had underlying oedematous moderate acute pancreatitis, hepatic steatosis, hepatosplenomegaly and alcohol dependence. On 4 April 2020, he was admitted in hospital of Poland, with positive SARS-CoV-2 (molecular test result obtained on 3 April 2020). He had previously been hospitalised for 2 weeks in another medical centre due to severe acute pancreatitis, presenting with acute-onset upper abdominal pain, metabolic acidosis and features of multi-organ failure. Empiric antimicrobial therapy with vancomycin and imipenem/cilastatin and total parenteral nutrition (TPN) were administered that time. On 27 March 2020, he underwent chest high-resolution CT-scan and abdomen-pelvis contrast-enhanced CT scans, which showed diffuse enlargement, shaggy contour of the pancreas without contrast enhancement of pancreatic neck, body and tail, oedema and blurring of peripancreatic fat planes, acute peripancreatic and intraperitoneal fluid collection, bilateral atelectasis in lower lung segments and pleural fluid collections up to 24mm on the left side and up to 18mm on the right side. No COVID-19 imaging findings were noted. He was then transferred to the latest hospital (latest presentation) to continue the treatment due to SARS-CoV-2 infection. Following admission, he received IV paracetamol 1000mg four times daily and oxygen supplementation through a nasal cannula, and his oxygen saturation increased to 95%. Off-label therapy with vancomycin 1000mg twice daily, IV meropenem 1000mg three times a day and SC dalteparin sodium [dalteparin] 7500 IU once daily were administered for COVID-19. He received off-label oral chloroquine 500mg twice a day for COVID-19. Blood and urine culture tests were negative. Of note, hepatitis B surface antigen, hepatitis C antibodies and HIV antigen were all negative. He was provided with a mechanical soft diet, with good clinical tolerance. On day 2, his vital parameters were stable, and he received off-label oral azithromycin 500mg daily for COVID-19. On days 3 through six of hospitalization, vital parameters remained stable except fever (despite paracetamol and dipyrone [metamizole] treatment), mild dry cough and shortness of breath with oxygen saturation at 91–94%, while breathing ambient air. Investigations showed necrosis of more than 50% of pancreatic parenchyma (body and tail), peripancreatic and along Gerota’s fascia fluid collections, and acute necrosis collection (ANC) along the greater curvature of the stomach. On day 5 a chest X-ray demonstrated diffused bilateral alveolar consolidations. On day 6, an abdominal ultrasound and emergency chest high resolution (HR) CT were performed. The HRCT showed widespread, multifocal, bilateral groundglass opacities (GGO) typical for COVID-19 pneumonia and ultrasound showed hepatic enlargement up to 180mm, enlargement of pancreas up to 30
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