COVID-19 in a Patient With Rheumatoid Arthritis During Tocilizumab Treatment

A 51-year-old woman with rheumatoid arthritis receiving tocilizumab (TCZ) developed nasal discharge, mild cough, and respiratory distress in early April 2020. Her daughter, living with her, was admitted to the hospital for COVID-19 (coronavirus disease 2019). The symptoms continued, and the patient also tested positive for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) by nasopharyngeal swab and quantitative reverse transcription–polymerase chain reaction on April 15, 2 weeks after her last TCZ injection. Chest computed tomography (CT) demonstrated ground-glass opacity mainly involving the peripheral region in the bilateral lungs (Fig. A). She was diagnosed with COVID-19. As the symptoms were mild, and her oxygen saturation was not low, she was observed at home without specific treatment. Tocilizumab was temporarily withdrawn. The respiratory symptoms were not exacerbated, and chest CT revealed improvement of the ground-glass opacities on April 24 (Fig. B). However, her arthralgia recurred on April 20. On May 13, the respiratory symptoms improved, CT confirmed the disappearance of ground-glass opacities (Fig. C), and SARS-CoV-2 was not detected by polymerase chain reaction. On May 18, TCZ was resumed, and arthritis improved.

FIGURE.

Findings on chest CT. A, On April 15, 2 weeks after the last TCZ injection, chest CT demonstrated ground-glass opacity (arrows) mainly involving the peripheral region in the bilateral lungs. B, On April 24, CT revealed improvement of the ground-glass opacities (arrows). C, On May 13, CT confirmed the disappearance of the ground-glass opacities.

Immunosuppressive agents are empirically discontinued in the event of severe infection. In contrast, several reports demonstrated the efficacy of TCZ against the respiratory symptoms of COVID-19.^1–3 Tocilizumab may inhibit the excessive immune response due to cytokine storm. When patients develop COVID-19 during TCZ therapy, we must decide whether to withdraw TCZ to reduce the risk of severe infection or to continue it to inhibit cytokine storm. In this patient, lung infiltration did not progress and cytokine storm did not develop after the withdrawal of TCZ. In addition, TCZ was also discontinued in a patient with scleroderma without exacerbation of respiratory symptoms.⁴ Tocilizumab can be discontinued when patients develop COVID-19 without cytokine storm. However, we need to examine more patients to conclude if we can withdraw TCZ in COVID-19.