SESSION TITLE: Medical Student/Resident Critical Care Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: As the Coronavirus Disease 2019 (COVID-19) pandemic continues to spread globally, there is a need for medications to treat the virus and modulate the immune system response. It has been postulated that the main reason COVID-19 pneumonia develops into acute respiratory syndrome (ARDS) is an overstimulated immune system. Tocilizumab, an interleukin-6 (IL-6) receptor inhibitor, is thought to influence the immune response in patients with COVID-19 by reducing inflammation mediated damage to the lungs and severity of lung injury. However, reduction of inflammation may lead to increased risk of superimposed infection. In this report we present a case of COVID-19 pneumonia treated with tocilizumab complicated by lung abscesses.
CASE PRESENTATION: 62 year old man with sarcoidosis presented to the hospital for dyspnea. His exam was remarkable for hypoxemia and bilateral inspiratory crackles in the lower lung fields. Bloodwork showed lymphopenia and elevated C-reactive protein. Chest x-ray showed right lower lobe opacities. Using reverse transcription polymerase chain reaction he tested positive for SARS-CoV-2. His respiratory status continued to deteriorate requiring intubation and mechanical ventilation. He received tocilizumab 400mg on day 11. He was placed in prone on day 11 for 16 hours to improve oxygenation. On day 23 a chest tube was inserted for hydropneumothorax. Pleural fluid grew Burkholderia cepacia and Streptococcus pyogenes along with Stenotrophomonas maltophilia growing from tracheal aspirate. Computed tomography scan of the chest revealed multiple right-sided parenchymal lung cavities with air-fluid levels. He was treated with vancomycin and piperacillin/tazobactam. Patient underwent tracheostomy on day 25 and required another chest tube placement for additional drainage. He gradually improved and was discharged to a rehabilitation facility.
DISCUSSION: In our case report we hypothesize that tocilizumab administration could have predisposed our patient with COVID-19 to develop superimposed bacterial infection leading to formation of multiple lung abscesses due to a diminished innate immune response. Furthermore, as a hospital acquired infection, gram negative bacteria would be most commonly implicated. We suggest close monitoring and early initiation of antibacterial therapy targeting gram negative pathogens in patients with COVID-19 pneumonia who receive treatment with tocilizumab.
CONCLUSIONS: In conclusion, tocilizumab is a therapy that further studies should continue to explore, as the pathophysiology in COVID-19 pneumonia has been shown to be partially driven by overexpression of IL-6. Yet, tocilizumab should be used with caution, as it increases the risk of superimposed microbial infections. Additional studies need to look into the timing of administration of tocilizumab and which subset of patients could benefit from the IL-6 regulation in this type of pneumonia.
Reference #1: Giamarellos-Bourboulis et al. Complex Immune Dysregulation in COVID-19 Patients with Severe Respiratory Failure. Cell Host & Microbe 27, 1–9. June 10, 2020
Reference #2: Yeimer Ortiz-Martíneza. Tocilizumab: A new opportunity in the possible therapeutic arsenal against COVID-19. Travel Medicine and Infectious Disease. April 15, 2020. 1477-8939
Reference #3: Luo P, Liu Y, Qiu L, Liu X, Liu D, Li J. Tocilizumab treatment in COVID-19: A single center experience. J Med Virol. 2020;1–5. https://doi.org/10.1002/jmv.25801
DISCLOSURES: No relevant relationships by John Gorski, source=Web Response
No relevant relationships by Maxim Kashin, source=Web Response
No relevant relationships by Ruth Minkin, source=Web Response