Use of Tocilizumab for COVID-19-Induced Cytokine Release Syndrome: A Cautionary Case Report

Jared Radbel; Navaneeth Narayanan; Pinki J Bhatt

doi:10.1016/j.chest.2020.04.024

Use of Tocilizumab for COVID-19-Induced Cytokine Release Syndrome: A Cautionary Case Report

Chest. 2020 Jul;158(1):e15-e19. doi: 10.1016/j.chest.2020.04.024. Epub 2020 Apr 25.

Authors

Jared Radbel¹, Navaneeth Narayanan², Pinki J Bhatt³

Affiliations

¹ Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ. Electronic address: jr1106@rwjms.rutgers.edu.
² Department of Pharmacy Practice and Administration, Rutgers-Ernest Mario School of Pharmacy, New Brunswick, NJ.
³ Division of Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ.

Abstract

Novel coronavirus disease 2019 (COVID-19) emerged in late December 2019 in Wuhan, China. Since then, COVID-19 has become a pandemic affecting more than 4.1 million people worldwide. Patients with COVID-19 have a wide spectrum of manifestations, one being cytokine release syndrome (CRS) and its fatal correlate, secondary hemophagocytic lymphohistiocytosis (sHLH). Anti-cytokine therapy such as tocilizumab, an IL-6 receptor antagonist, is a potential treatment for COVID-19; however, data regarding the efficacy of this anti-IL-6 therapy are currently lacking. We report two cases of patients who received a diagnosis of COVID-19 complicated by CRS and were treated with tocilizumab. Both patients progressed to sHLH despite treatment with tocilizumab, and one developed viral myocarditis, challenging the safety and clinical usefulness of tocilizumab in the treatment of COVID-19-induced CRS. These cases highlight the need for clinical trials to determine optimal patient selection and timing for the use of tocilizumab during this disease process.

Keywords: COVID-19; critical care; cytokines; viral disease.

Published by Elsevier Inc.

Publication types

Case Reports

MeSH terms

Adult
Aged
Anti-Infective Agents / administration & dosage
Anti-Inflammatory Agents / administration & dosage
Antibodies, Monoclonal, Humanized / administration & dosage*
Azithromycin / administration & dosage
Betacoronavirus / isolation & purification
C-Reactive Protein / analysis
COVID-19
Clinical Deterioration
Coronavirus Infections* / complications
Coronavirus Infections* / diagnosis
Coronavirus Infections* / physiopathology
Coronavirus Infections* / therapy
Cytokine Release Syndrome* / blood
Cytokine Release Syndrome* / therapy
Cytokine Release Syndrome* / virology
Fatal Outcome
Female
Humans
Hydroxychloroquine / administration & dosage
Hypoxia / etiology
Hypoxia / therapy
Lymphohistiocytosis, Hemophagocytic* / blood
Lymphohistiocytosis, Hemophagocytic* / therapy
Lymphohistiocytosis, Hemophagocytic* / virology
Male
Myocarditis / therapy
Myocarditis / virology
Pandemics*
Pneumonia, Viral* / complications
Pneumonia, Viral* / diagnosis
Pneumonia, Viral* / etiology
Pneumonia, Viral* / physiopathology
Pneumonia, Viral* / therapy
Respiration, Artificial / methods
SARS-CoV-2
Shock, Septic / etiology
Shock, Septic / therapy

Substances

Anti-Infective Agents
Anti-Inflammatory Agents
Antibodies, Monoclonal, Humanized
Hydroxychloroquine
Azithromycin
C-Reactive Protein
tocilizumab