SESSION TITLE: Fellows' COVID-19
SESSION TYPE: Fellow Case Reports
PRESENTED ON: October 18-21, 2020
INTRODUCTION: Interleukin-6 (IL-6) drives the inflammatory response in patients with Covid-19 infection and can sometimes present as cytokine storm. Sarilumab, an IL-6 inhibitor may have the potential for reducing the overactive inflammatory immune response associated with the COVID-19 virus. The potential complications of this experimental treatment in this setting are still unknown.
CASE PRESENTATION: 64-year-old man with coronary artery disease and obesity was admitted for Covid-19 pneumonia. He received a 5-day course of hydroxychloroquine and azithromycin. His inflammatory markers continued to worsen and his clinical picture was concerning for cytokine storm. He received sarilumab, an IL-6 inhibitor. He was started on empiric broad-spectrum antibiotics for a presumed bacterial superinfection. His hospital course was complicated by renal failure requiring renal replacement therapy. He also received convalescent plasma on day 17. Given prolonged intubation, the patient underwent tracheostomy placement on day 25. On day 26, the patient’s tracheostomy tube had become dislodged resulting in cardiac arrest with successful cardiopulmonary resuscitation. The patient was noted to have rectal bleeding on day 33 with subsequent colonoscopy revealing ischemic colitis. Biopsies of the colon revealed cytomegalovirus (CMV), and he was started on ganciclovir. This finding was concerning that the use of an IL-6 inhibitor, in addition to his acute illness, had placed him at an increased risk of CMV infection.
DISCUSSION: No prospective studies have yet specifically assessed covid-19 superinfections in the setting of IL-6 inhibitor use. It is well reported in the literature that critically ill patients are susceptible to CMV infection and may be associated with poor outcomes (1). The common adverse drug reactions seen in clinical trials for sarilumab include upper respiratory tract and urinary tract infections, as well as neutropenia and increased liver function tests (2). As covid-19 proceeds, more literature is reported on IL-6 as an important marker of inflammation to recognize severe covid-19 disease, thus prompting the use of IL-6 inhibitors (3). Prospective studies are needed to evaluate data on superinfections and outcomes regarding the use of IL-6 inhibitors in critically ill patients infected with covid-19. To our knowledge, this is the first reported case of CMV colitis due to IL-6 inhibitor administration in the setting of covid-19 infection
CONCLUSIONS: IL-6 is a marker of inflammation that has been used as a reference during the covid-19 pandemic in order to guide the use of IL-6 inhibitors. Randomized prospective trials to assess clinical outcomes are needed in order to provide guidelines regarding IL-6 inhibitors use in covid-19 infection.
Reference #1: Osawa R, Singh N. Cytomegalovirus infection in critically ill patients: a systematic review. Critical Care 2009, 13:R68
Reference #2: McCarty D, Robinson A. Efficacy and safety of sarilumab in patients with active rheumatoid arthritis Ther Adv Musculoskel Dis. 2018,10(3) 61–67
Reference #3: Aziz M, Fatima R, Assaly R. Elevated Interleukin-6 and Severe COVID-19: A Meta-Analysis. Journal of medical virology. 28 April 2020
DISCLOSURES: No relevant relationships by Nasheena Jiwa, source=Web Response
No relevant relationships by Kiran Lorick, source=Web Response
No relevant relationships by Rahul Mutneja, source=Web Response