Tocilizumab

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 52-year-old man developed lobar pneumonia following off label treatment with tocilizumab for COVID-19.

The man, who had a history of diabetes, admitted to the hospital with fever, shortness of breath, sweating and cough. His diabetes was controlled with metformin. Subsequently, he was diagnosed with COVID-19 and received off label treatment with chloroquine, oseltamivir [Tamiflu], lopinavir/ritonavir [Kaletra], vancomycin, ribavirin and levofloxacin. He also received oxygen and other symptomatic therapies. Despite the treatments, he developed respiratory distress on day 12 of the admission and his oxygen level was 60%. Hence, he was shifted to the ICU, where non-invasive ventilation was provided with positive end-expiratory pressure. One day after the invasive ventilation, his oxygen saturation level was in the range of 65−80%. Therefore, off label treatment with injection of tocilizumab 400mg vial [Actemra; route not stated] was given and his oxygen saturation level increased to 90%. Eventually, his COVID-19 had recovered. However, he had increase in the endotracheal tube secretion that became purulent on day 8 after tocilizumab administration. His lab test showed leukocytosis. His x-ray and CT scan of the chest showed lobar pneumonia and it was considered that the lobar pneumonia was secondary to tocilizumab.

The man was treated with colchicine. But, his sputum examination showed acinetobacter sensitive to colchicine. His subsequent treatment and non-invasive adjuvant ventilation led to resolution of the lobar pneumonia and he was discharged with oxygen saturation level more than 92%. No shortness of breath or respiratory distress were noted at the time of discharge.