Methylprednisolone/tocilizumab

Author Information

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 58-year-old man developed fatal disseminated mucormycosis caused by Rhizopus microsporus fungi during off-label immunosuppressive therapy with methylprednisolone and tocilizumab for COVID-19 [routes not stated; not all dosages stated].

The man who had history of type 2 diabetes mellitus and hypertension, was hospitalised to another hospital for acute respiratory failure caused by COVID-19. Despite, an off label treatment with methylprednisolone 1g three times a day and tocilizumab with concomitant remdesivir and mechanical ventilation support, the respiratory failure gradually worsened.

On day 6 of the symptoms onset, the man was transferred to another hospital. He was placed on pressure-controlled ventilation. Blood biochemistry showed severe inflammatory response, poor glycaemic control, liver dysfunction, pancreatic damage and acute kidney injury. CT scan showed wide spread ground-glass opacities, consolidations in bilateral lungs and pancreatic enlargement. On day 16, venovenous extracorporeal membrane oxygenation was started. On day 29, he developed right renal infarction and left main pulmonary artery thromboembolism. On day 34, he developed right frontal lobe subcortical haemorrhage. Eventually, on day 36, he died due to brain herniation and multiple organ failure. Five hours later, autopsy showed lungs were markedly oedematous and collapsed, extensive haemorrhagic infarction in both the lungs, Pulmonary arteries were obstructed with emboli comprising several fungal balls and neutrophils, fungus with thick, distorted mycelium, lacked bulkheads and had an irregular angle of branching. Grocott staining and periodic acid-schiff staining of the fungal body revealed positive findings, which suggested that the fungus was Mucor. Subsequently, DNA analysis identified Rhizopus microsporus. Mucor was noted in the heart, right kidney, liver, right adrenal gland and cerebellum, which resulted in infarction and thromboangiitis in these organ. Based on the autopsy findings it was considered that, he was suffered from both multiple embolisms caused by Mucor and COVID-19-related coagulopathy. It was concluded that he died because of multiple organ failure caused by disseminated mucormycosis [duration of treatments to reaction onset not stated].

» Editorial comment:Details of this case report have previously been published and processed for Adis PV [see Reactions 1887 p266; 803623085 ].