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Case Report: IL-6 inhibitor in confirmed COVID-19 cytokine storm syndrome
S. Thomas Yadegar, MD and Shahin Delkhah, MD
Providence Cedars-Sinai Tarzana Medical Center

Date of Presentation: March 28, 2020

Case Presentation
A 62-year-old-male with a past medical history of coronary artery disease, hypertension and chronic obstructive pulmonary disease presented to the emergency department with heartburn, shortness of breath and 5-day history of cough. He denied any recent travel history or known ill contacts.

Physical Exam
In the emergency department, the patient was noted to have temperature of 36.8C, pulse of 108 bpm, blood pressure of 140/80 mmHg and an oxygen saturation of 93% on room air.

Pertinent Laboratory Values
White blood cell count was 10.6 K/uL, hemoglobin was 14.6 g/dL, and platelet count was 515 K/uL. Procalcitonin was 0.11 mg/mL. D-dimer was 3.50 ug/mL FEU, CRP was 7.16 mg/dL and ferritin was 1,191 ng/mL. A nasopharyngeal swab testing for SARS-CoV-2 by PCR yielded a positive result five days after initial testing in the emergency department.

Pertinent Imaging
The patient underwent chest x-ray in the emergency department which revealed ill-defined patchy bilateral pulmonary infiltrates.

Treatment and Outcomes
The patient was admitted into the telemetry unit with droplet and contact isolation. He received supplemental oxygen at 2 liters per minute (LPM) via nasal cannula. As the patient was monitored over the next 48 hours, his oxygen requirements increased from 2 LPM to 6 LPM. Two days after admission, his CRP significantly increased to 17.71 mg/dL. Three days after admission, as a result of clinical decompensation and CRP elevation, the patient was suspected to be COVID-19 positive and was initiated on hydroxychloroquine (initial dose 400 mg orally twice daily x 1 day; continuing dose 200 mg orally twice daily x 4 days) and azithromycin (initial dose 500 mg once orally; continuing dose 250 mg orally once daily x 4 days). Despite this treatment, the patient continued to decompensate with increasing tachypnea and no improvement in oxygenation. The rapid response team was contacted on the telemetry floor and the patient subsequently was transferred to the intensive care unit. The patient continued to decompensate and was given one subcutaneous injection of sarilumab 200 mg in the morning five days after admission. Approximately two hours later, the patient’s CRP level decreased to 13.85 mg/dL (see Table 1). The patient’s oxygenation improved later in the afternoon to 94% on 2 LPM and his overall clinical status improved significantly. On the sixth day of the patient’s hospitalization course, the patient was on room air at 94% saturation and his clinical status continued to improve. On the seventh day after admission, his CRP had decreased to 4.51 mg/dL. The patient continued to remain stable and has subsequently been discharged home.

Lessons Learned
Based on monitoring of ferritin and CRP levels, exclusion of alternate etiologies of patient decompensation and close monitoring of the patient’s clinical status, cytokine storm syndrome was diagnosed and treated with early and aggressive therapy with IL-6 inhibitor. Sarilumab was utilized due to institutional availability, and can be used as first-line therapy for COVID-19 patients with confirmed cytokine storm syndrome.