Methylprednisolone/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 61-year-old man developed life threatening methicillin-sensitive Staphylococcus aureus (MSSA) costochondritis and chest wall abscess during off-label treatment with tocilizumab and methylprednisolone for COVID-19 pneumonia.

The man was hospitalised with the diagnosis of COVID-19 infection. Subsequently, he started receiving treatment with favipiravir, off-label hydroxychloroquine and off-label azithromycin. On day 6, he was shifted to ICU. He developed cytokine release syndrome (CRS) with severe hyperferritinaemia and lymphopenia. He was placed on high-flow oxygen support and received off-label IV tocilizumab 400mg. On Day 2 of ICU stay (7 days after hospitalisation), he developed acute hypoxemic respiratory failure progression rapidly and received a second dose of tocilizumab. Thereafter, he was intubated due to worsening hypoxemia, paradoxical abdominal respiration and accessory muscle use. Later, a central venous catheter was placed in the right jugular vein. He was extubated after 8 days of mechanical ventilation support and was discharged from the ICU. After 1 day discharge from the ICU, he experienced the sudden onset of right shoulder and chest pain radiating to the right arm. His pain aggravated by coughing, sneezing, deep breathing and movements of the right shoulder and torso. On physical examination showed normal bilateral upper extremity muscle strength and glenohumeral joint range of motion and was afebrile. He experienced extremely painful active and passive movements of the right shoulder. There was swelling, redness and warmth seen around the right parasternal region. The second and third costochondral joints palpation caused pain in a referred distribution and reproduced his symptoms. His chest radiograph was unremarkable. Laboratory findings showed mildly elevated serum CRP, normal leucocyte count and moderate lymphopenia, with no any other significant abnormalities. A computed tomography scan showed bilateral diffuse ground glass opacities, consolidation, crazy-paving pattern, degeneration in the right glenohumeral joint, minimal swelling of superficial subcutaneous tissues in the second and third right costal cartilage. He was suspected for Tietze syndrome

The man was received paracetamol for 3 days. But, his pain progressively increased and spread into the neck. He was treated with tramadol and diclofenac. He also received off-label IV methylprednisolone 40mg for 3 days, as he was oxygen-dependent. In spite of steroid and NSAID's, his shoulder and chest pain that radiated to the neck pain increased. His sternoclavicular joint was remarkably red, swollen and very tender. A chest and right shoulder MRI showed the joints which revealed a fluid collection in the right sternoclavicular joint with extension into the chest cavity, indicative of a chest wall abscess. A post-contrast T1-weighted images revealed the inflammatory changes and a central avascular area within the abscess. Later, a CT-guided fine needle aspiration of the lesion taken 10mL of purulent liquid and a gram stain test showed numerous polymorphonuclear leucocytes without any bacteria with negative acid-fast stain. Later, the culture of the liquid showed MSSA. He was diagnosed with life threatening MSSA costochondritis and chest wall abscess secondary to tocilizumab and methylprednisolone. Due to beta-lactam allergy, he was treated with linezolid. He showed improvement and was discharged with clindamycin. At one month of follow-up, repeat CT and MRI revealed a decrease in the diameter and content of the abscess.