Rapid and Impressive Response to a Combined Treatment with Single-Dose Tocilizumab and NIV in a Patient with COVID-19 Pneumonia/ARDS.
Marco CascellaImmacolata MauroElvio De BlasioAnna CrispoAlfredo Del GaudioSabrina BimonteArturo CuomoPaolo Antonio AsciertoPublished in: Medicina (Kaunas, Lithuania) (2020)
Treatment of acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia (CARDS) represents a clinical challenge, requiring often invasive mechanical ventilation (IMV). Since the pathogenesis of CARDS it probably involves a direct viral attack to pulmonary and endothelium cells, and immune-mediated inflammation with dysfunctional coagulation, it was suggested to interfere with interleukin-6 (IL-6) activity by using the IL-6 receptor monoclonal antibody tocilizumab (TCZ). We reported the case of a 54-year-old 100 kg male COVID-19 patient (BMI 29) with severe respiratory insufficiency featuring dyspnea and hypoxia (SpO2 89% on room; PaO2 53 mmHg). Despite treatment with antiviral and non-invasive ventilation (NIV), after 24 h there was a progressive worsening of clinical conditions with higher fever (40 °C), increased dyspnea, and hypoxia (PaO2/FiO2 or P/F ratio of 150). The patient was at the limit to be sedated and intubated for IMV. He was treated with tocilizumab (8 mg/Kg i.v., single shot 800 mg) and NIV in the prone positioning. After only 96 h, the clinical, laboratory, and imaging findings showed incredible improvement. There was an important gain in oxygenation (P/F 300), a decrease of C-reactive protein values, and a decrease of the fever. Both the neutrophil-to-lymphocyte ratio (NLR) and the derived NLR ratio dropped down to 44%. Chest imaging confirmed the favorable response. This case suggested that for CARDS management efforts are needed for reducing its underlying inflammatory processes. Through a multiprofessional approach, the combination of IL-6-targeting therapies with calibrated ventilatory strategies may represent a winning strategy for improving outcomes.
Keyphrases
- acute respiratory distress syndrome
- mechanical ventilation
- sars cov
- coronavirus disease
- extracorporeal membrane oxygenation
- rheumatoid arthritis
- respiratory failure
- intensive care unit
- high resolution
- monoclonal antibody
- case report
- multiple sclerosis
- oxidative stress
- nitric oxide
- type diabetes
- pulmonary hypertension
- systemic lupus erythematosus
- juvenile idiopathic arthritis
- mass spectrometry
- cancer therapy
- signaling pathway
- drug delivery
- weight loss
- combination therapy
- insulin resistance
- adipose tissue
- weight gain
- quality improvement
- rheumatoid arthritis patients
- disease activity
- blood flow
- fluorescence imaging