Calm Before The Storm: Covid-19 And Cytokine Storm Syndrome

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: COVID-19 is responsible for a large pandemic worldwide Multiple cases have been reported of a hyperinflammatory immune response, similar to cytokine storm syndrome (CSS) usually seen in cancer patients receiving CAR T-cell therapy This can lead to a rapid multi-organ failure in patients Anti-inflammatory medications such as tocilizumab have been used for this condition CASE PRESENTATION: A 22-year-old female with a history of mixed connective tissue disease on hydroxychloroquine (HCQ) and methotrexate presented with 3 weeks of dyspnea, sore throat, cough and fevers She had tested positive for SARS-CoV-2 and her symptoms rapidly worsened despite initial conservative management She was febrile and tachycardic upon presentation Her blood pressure remained normal and she was saturating \u003e98% on ambient air CBC showed lymphopenia of 0 52 10*3/uL Her lactate dehydrogenase was 249 U/L, ferritin was 145 ng/ml, d-dimer was 0 49 ug/ml and CRP was 56 8 mg/L A chest x-ray (CXR) showed bilateral consolidations She continued to deteriorate, with worsening fevers, tachypnea and hypoxia necessitating intubation The following day, a CXR showed worsening bilateral infiltrates and an arterial blood gas revealed a PaO2/FiO2 (PF) ratio of 62 on 100% FiO2, consistent with severe ARDS Paralysis and proning were initiated She failed to improve and repeat lab work showed that ferritin, D-dimer, and CRP values had increased to 843 ng/ml, 3 24 ug/ml and 233 5 mg/L, respectively Her IL-6 level was elevated at 106 8 pg/ml She was given one dose of tocilizumab (8 mg/kg) It resulted in rapid improvement in her clinical status over the next two days Repeat inflammatory markers were decreasing Her PF ratio improved to 254 on an FiO2 of 100% and rapidly weaned on the following day She was later extubated and discharged home with close follow-up DISCUSSION: COVID-19 has been shown to exhibit a wide range of presentations In most cases, the physiologic immune response is appropriately regulated and self-limited In certain patients, an uncontrolled immune activation, also known as CSS has been reported This is associated with pro-inflammatory cytokines such as IL-1 and IL-6 A similar phenomenon was observed in SARS-CoV-1 and MERS-CoV infection Tocilizumab is a monoclonal antibody which targets IL-6 receptors and has shown to have favorable results in COVID-19 patients by suppressing the severe immune response Our patient had rapid improvement, both clinically and in her inflammatory markers after being given the medication CONCLUSIONS: Patients can develop cytokine storm syndrome when suffering from COVID-19 Tocilizumab therapy has been shown to have favorable outcomes as it targets IL-6, a pro-inflammatory marker This case highlights a young patient with a severe presentation that responded remarkably well to tocilizumab Her chronic use of HCQ did not appear to limit the severity of the disease Reference #1: Mehta P, et al COVID-19: consider cytokine storm syndromes and immunosuppression Lancet 2020;395(10229):1033–1034 Reference #2: D McGonagle, K Sharif, A O’Regan, C Bridgewood The role of cytokines including Interleukin-6 in COVID-19 induced pneumonia and macrophage activation syndrome-like disease Autoimmun Rev, 102537 (2020) Reference #3: Qin C, et al Dysregulation of immune response in patients with COVID-19 in Wuhan, China [published online March 12, 2020] Clin Infect Dis https://doi org/10 1093/cid/ciaa248 DISCLOSURES: No relevant relationships by Japjot Chahal, source=Web Response No relevant relationships by Gaston Habib, source=Web Response No relevant relationships by Dragos Manta, source=Web Response No relevant relationships by Pardeep Masuta, source=Web Response No relevant relationships by Kartik Ramakrishna, source=Web Response