Use of Tociluzumab in the Thrombocytopenic COVID-19 Patient: A Challenge in the Therapeutic Approach.

Objective: Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. So far, approximately 250 million COVID19 positivity has been detected all over the world. Unfortunately, about five million of them resulted in death. Most people who get COVID19 show mild to moderate symptoms and recover without the need for special treatment. But some of them become seriously ill and need medical attention. Hypercytocinemia associated macrophage activation syndrome (MAS) may typically develop in severe COVID-19. In patients who develop MAS, SARS-CoV-2 infection causes strong inflammation in the lung, resulting in respiratory and systemic organ failure. Spesific antiviral treatment that will provide adequate improvement in the treatment of the disease has not been developed yet. For patients with MAS due to COVID-19, the physiological and pathological aspects are not enough well known but, current studies demonstrate the effectiveness of anti-cytokine therapy. Tocilizumab is a recombinant humanized monoclonal antibody, used as an anti-cytokine agent that acts as an interleukin-6 receptor antagonist. Indications for administration of tocilizumab in COVID-19 patients are hypoxia, lung infiltrates on chest radiograph, high inflammatory biomarkers (CRP >3 g/dL or ferritin >400 ng/mL). Contraindications are confirmed or suspected bacterial orofungal infections, platelet count <100,000/mm3, neutrophil count <2,000/mm3, and alanine aminotransferase (ALT) or aspartate aminotransferase (AST) upper limit of the normal range (50 U/L for ALT and 40 for AST). Case: A 60-year-old male patient, who had a bone marrow transplant due to multiple myeloma a year ago and was followed up in the pandemic service with the diagnosis of COVID-19 pneumonia, was admitted to the COVID-19 intensive care unit due to severe respiratory distress and a decrease in SpO2 . His respiratory rate was 35 per minute, C-reactive protein, ferritin, fibrinogen, D-dimer, lactate dehydrogenase values were high and platelet count was 39,46*103 per microliter. There were bilateral diffuse ground glass infiltrates on thorax computed tomography. Patient’s hypoxia continued and progression of infiltrates was observed on direct chest radiography. The hematology clinic was consulted for the indication of tocilizumab and it was decided to administer tocilizumab with platelet replacement (platelet count >30,000). Tocilizumab 8 mg/day administered two consecutive days with thrombocyte replacement. During this period, the patient was carefully followed up for hemorrhagic complications. On the fifth day of tocilizumab, inflammation markers were declined, The patient’s respiratory symptoms were resolved, PaO2/ FiO2 ratio raised up to 250. No bleeding disorder was encountered during this period. And the patient was successfully discharged to the ward. Conclusion: Although thrombocytopenia developed due to tocilizumab treatment, no bleeding event was reported in patients with thrombocytopenia. In the light of this literature information, we decided to apply tocilizumab treatment in a patient with MAS and thrombocytopenia and we did not encounter any bleeding complications. In conclusion, in the presence of thrombocytopenia in COVID-19 patients with MAS, tocilizumab can be administered under intensive care conditions with great care and very strict clinical follow-up. However, we think that more clinical experience and published data are needed on this subject. [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)