Experience of tocilizumab use for treatment of cytokine storm in patient with severe course of virus pneumonia caused by SARS-CoV-2 (Case report)

A clinical observation of tocilizumab efficacy for treatment of "cytokine storm" is presented in a patient with severe acute respiratory infection caused by SARS-CoV-2. Patient K., 57 years old with rapid progression of pneumonia caused by SARS-CoV-2 was admitted to hospital CHUZ " KB "RZDMeditsina" named after N. A. Semashko " on May 8, 2020, with complaints of fever up to 38,5°C for 5 days, cough and weakness. During 10 days of inpatient treatment, the patient's condition did not improve, shortness of breath increased (SpO290%, with oxygen therapy), the patient suffered from dry cough and fever up to 38,5°C. Due to increase in inflammatory process, manifested by an increase in C-reactive protein (CRP) > 75 mg/l, fever > 38°C, decrease in SpO2< 90%, leukopenia <  1,0  ×  109/l,  an  increase  in  ferritin  >1000  ng/ml  in  combination  with  a  70%  (CT3)  lesion  of  the lung tissue according to computed tomography, the patient was administered 160 mg of inteleukin -6  receptor  blocker   tocilizumab  intravenously.  In  the  next  48  hours  of  observation,  the  patient noted the disappearance of fever, an increase in SpO2to 94%, and a significant improvement in laboratory parameters. The effectiveness of tocilizumab can be explained by blocking interleukin-6-associated inflammatory response and requires further study in randomized clinical trials.

1. Babapoor-Farrokhran, S., Gill, D., Walker, J., Tarighati Rasekhic, R., Bozorgnia, B., & Amanullah, A. (2020). Myocardial injury and COVID-19: Possible mechanisms. Life Sciences, 253,117723. https://doi.org/10.1016/j.lfs.2020.117723

2. Coperchini, F., Chiovato, L., Croce, L., Magri, F., & Rotondi, M. (2020). The cytokine storm in COVID-19: An overview of the involvement of the chemokine/chemokine-receptor system. Cytokine and growth factor reviews, (53), 25–32. https://doi.org/10.1016/j.cytogfr.2020.05.003

3. Cotugno, M., Orgaz-Molina, J., Rosa-Salazar, V., Guirado-Torrecillas, L., García-Pérez, B. (2017). Right ventricular dysfunction in acute pulmonary embolism: NT-proBNP vs. troponin T. Medicina Clinica, 48(8), 339-344. https://doi.org/10.1016/j.medcli.2016.11.023.

4. Driggin, E., Madhavan, M. V., Bikdeli, B., Chuich, T., Laracy, J., Biondi-Zoccai, G., Brown, T. S., Der Nigoghossian, C., Zidar, D. A., Haythe, J., Brodie, D., Beckman, J. A., Kirtane, A. J., Stone, G. W., Krumholz, H. M., & Parikh, S. A. (2020). Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 Pandemic. Journal of the American College of Cardiology, 75(18), 2352–2371. https://doi.org/10.1016/j.jacc.2020.03.031

5. Guo, T., Fan, Y., Chen, M., Wu, X., Zhang, L., He, T., Wang, H., Wan, J., Wang, X., & Lu, Z. (2020). Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA cardiology, 5(7), 1–8. Advance online publication. https://doi.org/10.1001/jamacardio.2020.1017

6. Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., Zhang, L., Fan, G., Xu, J., Gu, X., Cheng, Z., Yu, T., Xia, J., Wei, Y., Wu, W., Xie, X., Yin, W., Li, H., Liu, M., Xiao, Y., Gao, H., Guo, L., Xie, J., Wang, G., Jiang, R., Gao, Zh., Jin, Q., Wang J., & Cao, B. (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 395(10223), 497–506. https://doi.org/10.1016/S0140-6736(20)30183-5

7. Lippi, G., Lavie, C. J., & Sanchis-Gomar, F. (2020). Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis. Progress in cardiovascular diseases, 63(3), 390–391. https://doi.org/10.1016/j.pcad.2020.03.001

8. Luo, P., Liu, Y., Qiu, L., Liu, X., Liu, D., Li, J. (2020). Tocilizumab treatment in COVID-19: a single center experience. Journal of Medical Virology, 92, 814–818. https://doi.org/10.1002/jmv.25801

9. Madjid, M., Safavi-Naeini, P., Solomon, S. D., & Vardeny, O. (2020). Potential effects of coronaviruses on the cardiovascular system: a review. JAMA cardiology, 5(7), 831–840. https://doi:10.1001/jamacardio.2020.1286

10. Porter, D., Frey, N., Wood, P. A., Weng, Y., & Grupp, S. A. (2018). Grading of cytokine release syndrome associated with the CAR T cell therapy tisagenlecleucel. Journal of hematology & oncology, 11(1), 35. https://doi.org/10.1186/s13045-018-0571-y

11. Radbel, J., Narayanan, N., & Bhatt, P. J. (2020). Use of Tocilizumab for COVID-19-Induced Cytokine release syndrome: a cautionary case report. Chest, S0012-3692(20)30764-9. https://doi.org/10.1016/j.chest.2020.04.024

12. Wang, D., Hu, B., Hu, C., Zhu, F., Liu, X., Zhang, J., Wang, B., Xiang, H., Cheng, Z., Xiong, Y., Zhao, Y., Li, Y., Wang, X., & Peng, Z. (2020). Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA, 323(11), 1061–1069. Advance online publication. https://doi.org/10.1001/jama.2020.1585

13. Xu, X., Han, M., Li, T., Sun, W., Wang, D., Fu, B., Zhou, Y., Zheng, X., Yang, Y., Li, X., Zhang, X., Pan, A., & Wei, H. (2020). Effective treatment of severe COVID-19 patients with tocilizumab. Proceedings of the National Academy of Sciences of the United States of America, 117(20), 10970–10975. https://doi.org/10.1073/pnas.2005615117

14. Ye, Q., Wang, B., & Mao, J. (2020). The pathogenesis and treatment of the `Cytokine Storm’ in COVID-19. The Journal of infection, 80(6), 607–613. https://doi.org/10.1016/j.jinf.2020.03.037

15. Zhou, F., Yu, T., Du, R., Fan, G., Liu, Y., Liu, Zh., Xiang, J., Wang, Y., Song, B., Gu, X., Guan, L., Wei, Y., Li, H., Wu, X., Xu, J., Tu, Sh., Zhang, Y., Chen, H., & Cao, B. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 395(20), 1054-1062. https://doi.org/10.1016/S0140-6736(20)30566-3