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Rapid and Impressive Response to a Combined Treatment with Single-Dose Tocilizumab and NIV in a Patient with COVID-19 Pneumonia/ARDS.
Medicina (Kaunas). 2020 Jul 27; 56(8)M

Abstract

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.

Authors+Show Affiliations

Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori-IRCCS-"Fondazione G. Pascale", 80131 Naples, Italy.Pneumology Unit, Ospedale Mauro Scarlato, 84018 Scafati (SA), Italy.Multidisciplinary Emergency Unit for COVID-19 Campania, 80100 Naples, Italy.Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori-IRCCS-"Fondazione G. Pascale", 80131 Naples, Italy.DSC Anestesia e Rianimazione 2, IRCCS Casa Sollievo Della Sofferenza, 71013 San Giovanni Rotondo (FG), Italy.Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori-IRCCS-"Fondazione G. Pascale", 80131 Naples, Italy.Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori-IRCCS-"Fondazione G. Pascale", 80131 Naples, Italy.Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori-IRCCS-"Fondazione G. Pascale", 80131 Naples, Italy.

Pub Type(s)

Case Reports

Language

eng

PubMed ID

32727107

Citation

Cascella, Marco, et al. "Rapid and Impressive Response to a Combined Treatment With Single-Dose Tocilizumab and NIV in a Patient With COVID-19 Pneumonia/ARDS." Medicina (Kaunas, Lithuania), vol. 56, no. 8, 2020.
Cascella M, Mauro I, De Blasio E, et al. Rapid and Impressive Response to a Combined Treatment with Single-Dose Tocilizumab and NIV in a Patient with COVID-19 Pneumonia/ARDS. Medicina (Kaunas). 2020;56(8).
Cascella, M., Mauro, I., De Blasio, E., Crispo, A., Del Gaudio, A., Bimonte, S., Cuomo, A., & Ascierto, P. A. (2020). Rapid and Impressive Response to a Combined Treatment with Single-Dose Tocilizumab and NIV in a Patient with COVID-19 Pneumonia/ARDS. Medicina (Kaunas, Lithuania), 56(8). https://doi.org/10.3390/medicina56080377
Cascella M, et al. Rapid and Impressive Response to a Combined Treatment With Single-Dose Tocilizumab and NIV in a Patient With COVID-19 Pneumonia/ARDS. Medicina (Kaunas). 2020 Jul 27;56(8) PubMed PMID: 32727107.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Rapid and Impressive Response to a Combined Treatment with Single-Dose Tocilizumab and NIV in a Patient with COVID-19 Pneumonia/ARDS. AU - Cascella,Marco, AU - Mauro,Immacolata, AU - De Blasio,Elvio, AU - Crispo,Anna, AU - Del Gaudio,Alfredo, AU - Bimonte,Sabrina, AU - Cuomo,Arturo, AU - Ascierto,Paolo Antonio, Y1 - 2020/07/27/ PY - 2020/06/05/received PY - 2020/07/09/revised PY - 2020/07/23/accepted PY - 2020/7/31/entrez PY - 2020/7/31/pubmed PY - 2020/8/7/medline KW - COVID-19 KW - acute respiratory distress syndrome (ARDS) KW - case report KW - cytokines KW - immunotherapy KW - inflammation JF - Medicina (Kaunas, Lithuania) JO - Medicina (Kaunas) VL - 56 IS - 8 N2 - 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. SN - 1648-9144 UR - https://www.unboundmedicine.com/medline/citation/32727107/Rapid_and_Impressive_Response_to_a_Combined_Treatment_with_Single-Dose_Tocilizumab_and_NIV_in_a_Patient_with_COVID-19_Pneumonia/ARDS L2 - https://www.mdpi.com/resolver?pii=medicina56080377 DB - PRIME DP - Unbound Medicine ER -