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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 65-year-old man developed COVID-19 penumonia during treatment with carboplatin, pemetrexed and pembrolizumab for stage IV non-small cell lung cancer.
The man had been diagnosed with stage IV non-small cell lung cancer (bilateral lung metastases) in February 2020. Due to the radiologic stage and molecular profile (programmed cell death ligand 1 and EGFR and BRAF mutations), he started receiving treatment with pembrolizumab, pemetrexed and carboplatin on 6 March 2020 [dosages and routes not stated]. His medical history was significant for smoking (15 pack-years), and he also received a vaccination for seasonal influenza. On 13 March 2020 (on admission day 1), he was admitted with fever for the last 24h and productive cough. On admission, physical examination showed that he was febrile and tachycardic with fine crackles heard at the right lung base. The arterial oxygen partial pressure/fractional inspired oxygen (P/F) ratio in room air was found to be 328. Additionally, grade 3 leucopenia and neutropenia were noted along with elevated CRP. On chest radiograph, no signs of interstitial pneumonia were observed. Subsequently, a nasopharyngeal swab for COVID-19 was performed. He received empirical treatment with broad-spectrum antibacterials [antibiotics] along with granulocyte colony-stimulating factors. On admission day 2, reverse transcriptase polymerase chain reaction test showed positive result for COVID-19 pneumonia. As a result, COVID-19 pneumonia secondary to chemoimmunotherapy with carboplatin, pemetrexed and pembrolizumab was considered.
Therefore, the man's chemoimmunotherapy with carboplatin, pemetrexed and pembrolizumab was stopped, and he received an off-label treatment with hydroxychloroquine 200mg twice daily, ritonavir 100 mg/day and darunavir 800 mg/day. Despite ongoing treatment with hydroxychloroquine, darunavir and ritonavir and oxygen supplementation, his clinical condition did not improve. The CRP levels further increased and interleukin-6 level was found to be 101 ng/L. By admission day 7, the P/F ratio had decreased to 58. The CT scan revealed areas of consolidation in the right and left lower lobes with diffuse ground glass opacities and interlobular and intralobular septal thickening. On admission day 8 and 9, he received an off-label treatment with his first and second dose of tocilizumab 8 mg/kg every 12h. As a result, an immediate clinical improvement was noted. The P/F ratio had decreased to 100 after the first dose of tocilizumab. Subsequently, the oxygen support was gradually decreased. After the second dose, the CRP level had decreased from 212 mg/L to 37 mg/L by 48h. After the administration of tocilizumab, the CT scan showed a reduction in the ground glass opacities. The lung tumour was also found to be stable. On admission day 13, he was discharged with a P/F ratio of 370 (in room air).
The man's chemoimmunotherapy with carboplatin, pemetrexed and pembrolizumab was restarted without complications after additional improvement in the ground glass opacities was noted on the second CT scan.
Reference
- Bonomi M, et al. Tocilizumab for COVID-19 Pneumonia in a Patient With Non-Small-cell Lung Cancer Treated With Chemoimmunotherapy. Clinical Lung Cancer 22: e67-e69, No. 1, Jan 2021. Available from: URL: 10.1016/j.cllc.2020.08.002 [DOI] [PMC free article] [PubMed]