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Arana Lucía1, Diaz Nelson1,2, Jose Gonzales-Zamora3, Carcausto Eduardo1,2, Muñoz Sara2, Alarco Oliver2, Esquivel Robert2, Cardenas Gianina2, Alave Jorge1,4
1.School of Medicine. Universidad Peruana Unión. Lima, Peru
2.Internal Medicine Unit. Clinica Good Hope. Lima, Peru
3.Infectious Diseases Division. University of Miami, Miller School of Medicine. Miami, USA.
4.Infectious Diseases Unit. Clinica Good Hope. Lima, Peru

1. Date of presentation: April, 21

2. Clinical Case:
A 57-year-old man, with no past medical history, presented with ten days of global headache and general malaise. He also complained of fever, cough and dyspnea for 3 days, which prompted his admission to the hospital.
Physical examination revealed a non-febrile patient with tachypnea (RR 20 bpm), tachycardia (HR 105 bpm), oxygen saturation (SO2) of 86% on room air and pulmonary crackles. Laboratory studies showed complete blood count with leukocytes of 10.3 K/μL and lymphopenia (830 cells/μL), C-reactive protein of 34.69 mg/dL, lactate dehydrogenase of 645 U/L (normal value: 135 – 225 U/L), ferritin of 1226 ng/mL, and D-dimer of 1.59mg/L. Arterial blood gas (ABG) showed severe hypoxemia (PO2 of 51 mmHg), mild hypocapnia (PCO2 of 29 mmHg), and SO2 of 89% on room air. Chest X -ray revealed bilateral interstitial infiltrates and CT scan showed multifocal peripheral ground glass opacities bilaterally with a consolidation process predominantly on posterior-basal segments (Fig 1). The electrocardiogram did not reveal significant abnormalities. SARS CoV-2 was detected by RT-PCR from nasopharynx. The patient was placed on non-rebreathing mask and was started on hydroxychloroquine (400 mg BID on first day and 200 mg BID for next four days), azithromycin (250 mg daily), prophylactic dose of enoxaparin (40mg SQ daily), meropenem (2 g TID), vancomycin (1 g every 12 hours), and methylprednisolone (0.5 mg/kg BID for 3 days).

During follow- up, the patient developed fever and worsening dyspnea (respiratory rate of 28 bpm). ABG revealed persistent hypoxemia (PO2 53.4 mmHg, SO2 of 89% on FiO2 of 80%), and IL-6 level was 36.8 pg/mL. The patient received a single dose of tocilizumab (400 mg), and four days later, C-reactive protein decreased to 0.61 mg/dL, and lymphocytes increased to 1703 cells/uL. His respiratory status improved, and his respiratory rate decreased to 20 bpm, not requiring admission to ICU. He remained hospitalized for 12 days after single dose of tocilizumab. Repeat CT scan revealed resolution of ground glass opacities but persistence of consolidation in posterior basal segments (Fig 2). The patient had a favorable clinical evolution and was discharged home saturating 94% on room air.

3. Learned lesson:
Tocilizumab was useful to prevent progression of ARDS in a patient who required mechanical ventilation. Although the hospital stay was prolonged, the arterial blood gas parameters were acceptable at discharge.