AORTIC VALVE ENDOCARDITIS AS A COMPLICATION OF TOCILIZUMAB TREATMENT IN COVID 19 PATIENT

Background

Tocilizumab works by blocking the IL-6 receptor. Most recent guidelines recommend against its use in COVID-19 management due to lack of beneficial effect on mortality and serious side effects.

Case

A 71year old man with bioprosthetic aortic valve was admitted with COVID-19 pneumonia. The patient received tocilizumab with marked signs of improvement and was discharged on prednisone. He got readmitted twice with S. aureus bacteremia treated with antibiotics. On second readmission the electrocardiogram showed third-degree heart block (Figure 1A). The transesophageal echocardiogram showed aortic valve vegetation with aortic root and aorto-mitral curtain thickening suspicious of abscess (Figure 1B). He underwent aortic root abscess drainage and implantation of redo bioprosthetic aortic valve with transvenous pacemaker placement (Figure 1C).

Decision-making

Tocilizumab is associated with fatal infections that may lead to hospitalization or death. Physicians should be cautious about superimposed infections while prescribing tocilizumab to patients with prosthetic heart valves. Our patient received steroids along with tocilizumab which likely acted as a concomitant immunosuppressant leading to aortic valve abscess.

Conclusion

Tocilizumab has been used experimentally in COVID-19 infection without any proven beneficial effects. This case highlights the adverse effects of immunosuppression caused by Tocilizumab in COVID-19 patients.