Question normal

Tariq Kewan, MD and Bassel Akbik, MD
Critical Care Department, Cleveland Clinic Foundation.

Date of presentation: 03/18/2020
Case Presentation
An 80 year-old male with past medical history of coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, and chronic kidney disease presented with sore throat, fever, productive cough and general fatigue. He denied any recent travel history or sick people contact.

Physical Exam
In the emergency department patient was tachycardiac , tachypneic, febrile (38.6 C) and hypoxic on room air. Chest exam was positive for bilateral crackles and wheeze.

Pertinent Laboratory values
White blood cell count was normal (4.87) and absolute lymphocyte count was low at (.5 k/uL) . Sepsis lactate was negative. Respiratory sputum culture didn’t grow any specific microorganisms. Streptococcus pneumonia and legionella antigens were negative. Assays to detect influenza viruses and a respiratory syncytial virus were all negative. A nasopharyngeal swab was positive for SARS-CoV-2 on real-time reverse transcription polymerase chain reaction (RT-PCR) assays. Triglyceride level was 185 mg/dl and interleukin 6 level was 14 pg/ml. Blood culture drawn at the date of admission came back negative.
Pertinent images
Chest X ray at the time of admission revealed new hazy right upper lobe lateral opacity and early lobar pneumonia. Chest X-ray after treatment showed mild interstitial prominent with significant improvement (figure-1).

Treatment and Outcomes
Patient was admitted to regular medical floor and started on azithromycin and hydroxychloroquine for total of 5 days. He was initially on 4 L NCL. After 2 days of admission his clinical condition deteriorated and he required ICU admission. He was intubated and started on phenylephrine and vasopressin for circulatory shock. He was diagnosed with cytokine release storm and was given one dose of 400 mg tocilizumab and methyl prednisone 60 mg daily for 6 days. After 2 days of tocilizumab, he was weaned off all pressors. Also, his CRP and ferritin dropped from 21.3 mg/dl and >100,000 ng/dl on day of ICU admission to 17.9 mg/dl and 1793 ng/dl after 2 days respectively. He was extubated after 12 days of tocilizumab treatment and transferred to regular medical floor on 4 L NCL.

Lessons Learned
Cytokine release storm (CRS) in patient with COVID-19 is critical and can take place very rapidly after COVID-19 diagnosis. Tocilizumab is a monoclonal antibody against IL-6 that can be used in COVID-19 ARDS patients with CRS. Tocilizumab can improve oxygenation and hemodynamic stability in COVID-19 patient with CRS.