1
|
Su S, Hu W, Chen X, Ren Y, Lu Y, Shi J, Zhang T, Zhang H, Wang M, Wang Y, Zhao F, Jin R, Liu Y, Zhang H, Liu G. Cardiac injury progression in children with multisystem inflammatory syndrome associated with SARS-CoV-2 infection: a review. Front Pediatr 2024; 12:1348016. [PMID: 38510081 PMCID: PMC10950994 DOI: 10.3389/fped.2024.1348016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/22/2024] [Indexed: 03/22/2024] Open
Abstract
The symptoms and signs of infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are milder in children than in adults. However, in April 2020, British pediatricians first reported that coronavirus disease 2019 (COVID-19) may present as multisystem inflammatory syndrome in children and adolescents (MIS-C), similar to that observed in Kawasaki disease. MIS-C can be associated with multiple systemic injuries and even death in children. In addition to digestive system involvement, cardiac injury is prominent. This article reviews the pathogenesis, clinical manifestations, and treatment of cardiac injury caused by MIS-C, which may help clinicians in early diagnosis and timely commencement of treatment.
Collapse
Affiliation(s)
- Song Su
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Wandong Hu
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Xiao Chen
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Ying Ren
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Yi Lu
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Jianguo Shi
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Tong Zhang
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Huan Zhang
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Meng Wang
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Yaping Wang
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Fen Zhao
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Ruifeng Jin
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Yong Liu
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Hongwei Zhang
- Epilepsy Center, Children’s Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Epilepsy Center, Jinan Children's Hospital, Jinan, Shandong, China
| | - Guohua Liu
- Department of Ophthalmology, Children's Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Department of Ophthalmology, Jinan Children's Hospital, Jinan, Shandong, China
| |
Collapse
|
2
|
Barahimi E, Defaee S, Shokraei R, Sheybani-Arani M, Salimi Asl A, Ghaem HM. Bacterial endocarditis following COVID-19 infection: two case reports. J Med Case Rep 2023; 17:274. [PMID: 37322551 DOI: 10.1186/s13256-023-03970-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND COVID-19, an emerging disease raised as a pandemic, urgently needed treatment choices. Some options have been confirmed as lifesaving treatments, but long-term complications must be clearly illustrated. Bacterial endocarditis is a less frequent disease among patients infected with SARS_COV_2 compared to other cardiac comorbidities in these patients. This case report discusses bacterial endocarditis as a potential adverse effect after administering tocilizumab, corticosteroids, and COVID-19 infection. CASE PRESENTATION In the first case, a 51-year-old Iranian female housewife was admitted to the hospital with fever, weakness, and monoarthritis symptoms. The second case is a 63-year-old Iranian woman who is a housewife admitted with weakness, shortness of breath, and extreme sweating. Both cases tested positive for Polymerase chain reaction (PCR) less than one month ago and were treated with tocilizumab and corticosteroid. Both patients were suspected of infective endocarditis. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the blood cultures of both patients. The diagnosis of endocarditis is confirmed for both cases. Cases are subjected to open-heart surgery, a mechanical valve is placed, and they are treated with medication. In subsequent visits, their condition was reported to be improving. CONCLUSION Adjacent to cardiovascular inclusion as COVID-19 disease complications, secondary infection taken after the organisation of immunocompromising specialists can result in basic maladies and conditions counting infective endocarditis.
Collapse
Affiliation(s)
- Elham Barahimi
- Infectious and Tropical Diseases Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Sahar Defaee
- Infectious and Tropical Diseases Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Rahele Shokraei
- Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | | | - Ali Salimi Asl
- Student Research Committee, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Hossein Montazer Ghaem
- Department of Surgery, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
| |
Collapse
|
3
|
Development of Evidence-Based COVID-19 Management Guidelines for Local Context: The Methodological Challenges. Glob Health Epidemiol Genom 2022; 2022:4240378. [PMID: 35492871 PMCID: PMC9020141 DOI: 10.1155/2022/4240378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has presented as a therapeutic challenge for clinicians worldwide due to its rapid spread along with evolving evidence and understanding of the disease. Internationally, recommendations to guide the management of COVID-19 have been created and updated continuously by the WHO and CDC, which have been locally adapted by different countries. Similarly, Pakistan's National Command Operation Center (NCOC), in its national COVID-19 management strategy, generated guidelines for national implementation. Keeping the guidelines updated has proved challenging globally and locally. Here, we present a summary of the process to assess the evidence, including a time-restricted systematic review based on NCOC Clinical Management Guidelines for COVID-19 Infections v4 published on 11th December 2020 version, correlating it with current recommendations and with input one of the guidelines authors, particularly noting the methodological challenges. Methods We conducted a systematic review synthesizing global research on treatment options for COVID-19 hospitalized patients, limiting it to pharmacological interventions for hospitalized COVID-19 patients included in Pakistan's NCOC's national guidelines v4 published on 11th December 2020. Each treatment recommendation's strength and quality of evidence was assessed based on the grading of recommendations assessment, development, and evaluation (GRADE) methodology. These were then compared to the most current living WHO COVID-19 pharmacological treatment guidelines v7.1. One of the authors of the NCOC guidelines reviewed and commented on the findings as well. Results We note that the data from our systematic review strongly supports corticosteroids use in treating severe and critically ill COVID-19 hospitalized patients correlating with WHO v7.1 guidelines 24 September 2021. However, evidence from our review and WHO v7.1 for the use of tocilizumab had some conflicting evidence, with data from our review until December 2020 supporting only a weak recommendation for its use, compared to the strong recommendation by the WHO for the use of tocilizumab in patients with severe or critical COVID-19 infection. Regarding the use of antibiotics and ivermectin use in treating COVID-19 hospitalized patients, data from our review and WHO v 7.1 recommend against their use. Conclusion Research data about the efficacy and safety of pharmacological interventions to treat hospitalized patients with COVID-19 are rapidly evolving, and based on it, the evidence for or against recommendations changes accordingly. Our study illustrates the challenges of keeping up with the evidence; the recommendations were based on studies up till December 2021, and we have compared our recommendations with the WHO v7.1, which showed some significant changes in the use of pharmacological treatment options.
Collapse
|
4
|
Amir M, Gafoor A, Iqbal Z, Ashraf S, Zeb S. Compassionate Use of Tocilizumab in Patients with Coronavirus Disease 2019 in a Low-resource Country, Pakistan: A Pilot Study. BIO INTEGRATION 2021. [DOI: 10.15212/bioi-2021-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract Background: We herein report our experience of optimized utilization of tocilizumab for patients with coronavirus disease 2019 (COVID-19) in a limited-resource tertiary care hospital.Methods: This single-center, single-arm, open-label, interventional
study was conducted to determine the effect of tocilizumab on the mortality of patients with COVID-19.Results: Fifty-nine patients were administered tocilizumab. Patients who received invasive respiratory support were identified to have a higher risk of mortality than those who
received oxygen support.Conclusion: Our study showed that the maximum benefit of tocilizumab was observed as a prophylactic treatment of cytokine syndrome in patients with COVID-19, particularly those with moderate to severe symptoms who are not receiving invasive respiratory support.TOCIPAK
<ext-link ext-link-type="uri" xlink:href="https://ensaiosclinicos.gov.br/rg/RBR-25rtydq">https://ensaiosclinicos.gov.br/rg/RBR-25rtydq</ext-link>; REBEC Number 11773
Collapse
Affiliation(s)
- Muhammad Amir
- Department of Pharmacy Services, Lady Reading Hospital-MTI, Peshawar, Pakistan
| | - Amir Gafoor
- Department of Gastroenterology and Hepatology, Lady Reading Hospital-MTI, Peshawar, Pakistan
| | - Zafar Iqbal
- Department of Pulmonology, Lady Reading Hospital-MTI, Peshawar, Pakistan
| | - Shehriyar Ashraf
- Department of Anesthesia and Critical Care, Lady Reading Hospital-MTI, Peshawar, Pakistan
| | - Salma Zeb
- Department of Acute Medical Unit, Lady Reading Hospital-MTI, Peshawar, Pakistan
| |
Collapse
|
5
|
Khurshid S, Rehman N, Ahmed S, Ahmad B, Khurshid M, Muhammad A, Siddiqi FA, Nayab D, Saleem H, Saleem Z. Early Fall in C-Reactive Protein (CRP) Level Predicts Response to Tocilizumab in Rapidly Progressing COVID-19: Experience in a Single-Arm Pakistani Center. Cureus 2021; 13:e20031. [PMID: 34987916 PMCID: PMC8717466 DOI: 10.7759/cureus.20031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction There are conflicting studies regarding the efficacy of tocilizumab use in coronavirus disease 2019 (COVID-19) disease. There is a special need to identify the parameters that could predict its response in early COVID-19 disease. Objective To report our experience with tocilizumab and correlate the magnitude of fall in c-reactive protein (CRP) as a predictor of its response to treatment in early COVID-19 disease. Methods All confirmed COVID-19 cases admitted to a tertiary healthcare hospital in Peshawar Pakistan, receiving ≥1 dose of intravenous tocilizumab, between March and September 2020 were included. Relevant clinical data of the patients were recorded and further divided into two categories based on the relative fall in CRP levels, 48 hours after tocilizumab administration. Adequate response (≥50% fall from baseline CRP), primary outcomes (fall in oxygen requirement and inflammatory biomarkers), and secondary outcome (all-cause mortality at day 28) were recorded. All outcomes were compared based on falls in CRP levels. Results A total of 27 patients were included. Males were 24 (88.8%) while females were three (11.1%). The mean age was 60.9±11.6 years. The mean day of illness at the time of tocilizumab administration was 4.26±3 days. After 48 hours of tocilizumab administration, 17 (62.9%) patients showed clinical improvement, with the mean SaO2/FiO2 ratio prior to treatment significantly increased (p<0.01). A significant reduction in CRP and ferritin levels was seen post-treatment (p <0.01 and p<0.01, respectively). Twenty (74.1%) patients demonstrated adequate response to tocilizumab while seven (25.9%) showed an inadequate response. Patients with adequate response had higher chances of improvement in oxygenation and lower in-hospital mortality (p-value 0.009 and 0.020, respectively). Conclusions Tocilizumab shows clinical improvement in a vast majority of patients. Being an early and sensitive predictor, a fall of ≥50% in CRP at 48 hours can be used to predict the overall response to tocilizumab as a guide to treatment.
Collapse
|
6
|
Mushtaq MZ, Mahmood SBZ, Almas A, Ather Wasti S, Ahsan Ali S. Tocilizumab in critically ill COVID-19 patients: An observational study. Int Immunopharmacol 2021; 102:108384. [PMID: 34838490 PMCID: PMC8604692 DOI: 10.1016/j.intimp.2021.108384] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/16/2021] [Accepted: 11/16/2021] [Indexed: 12/23/2022]
Abstract
Tocilizumab decreases inflammatory response in the cytokine storm which is one of the mechanisms behind the development of ARDS in COVID-19 patients. The objective of our study was to determine response of tocilizumab in patients suffering from COVID-19 by analyzing clinical parameters and inflammatory markers. A single-arm observational retrospective study was conducted from March 15, 2020 to March 15, 2021. Clinical outcomes in terms of mortality, weaning from mechanical ventilator, improvement in laboratory parameters including inflammatory cytokines, and length of hospital stay were documented. Reduction in values of inflammatory markers, and patients discharged home in stable condition were defined as an improvement after tocilizumab administration. A total of 514 patients received tocilizumab, majority of whom were critically sick 333 (64.8%). Out of the total sample 363 (70.6%) patients were discharged home in stable condition. Overall mean length of stay was 11.50 ± 8.4 days. There was significant difference in length of stay of patients who required invasive mechanical ventilation as compared to those who were kept only on supplemental oxygen (p < 0.05). Patients who were discharged home showed significant improvement in inflammatory markers and neutrophil to lymphocyte ratio as compared to those who expired (p < 0.05). A total of 21 (4.1%) patients had positive blood culture while 57 (11.1%) had positive culture of tracheal aspirate. Hence, tocilizumab is found to be a reasonable therapeutic option for worsening COVID-19 pneumonia by decreasing the need for mechanical ventilation. However, it is associated with adverse events including bacterial and fungal infections.
Collapse
Affiliation(s)
- Muhammad Z Mushtaq
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Saad B Z Mahmood
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Aysha Almas
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Syed Ather Wasti
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Syed Ahsan Ali
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan.
| |
Collapse
|
7
|
Rubio‐Rivas M, Forero CG, Mora‐Luján JM, Montero A, Formiga F, Homs NA, Albà‐Albalate J, Sánchez L, Rello J, Corbella X. Beneficial and harmful outcomes of tocilizumab in severe COVID-19: A systematic review and meta-analysis. Pharmacotherapy 2021; 41:884-906. [PMID: 34558742 PMCID: PMC8661749 DOI: 10.1002/phar.2627] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The results of studies of tocilizumab (TCZ) in COVID-19 are contradictory. Our study aims to update medical evidence from controlled observational studies and randomized clinical trials (RCTs) on the use of TCZ in hospitalized patients with COVID-19. METHODS We searched the following databases from January 1, 2020 to April 13, 2021 (date of the last search): MEDLINE database through the PubMed search engine and Scopus, using the terms ("COVID-19" [Supplementary Concept]) AND "tocilizumab" [Supplementary Concept]). RESULTS Sixty four studies were included in the present study: 54 were controlled observational studies (50 retrospective and 4 prospective) and 10 were RCTs. The overall results provided data from 20,616 hospitalized patients with COVID-19: 7668 patients received TCZ in addition to standard of care (SOC) (including 1915 patients admitted to intensive care units (ICU) with reported mortality) and 12,948 patients only receiving SOC (including 4410 patients admitted to the ICU with reported mortality). After applying the random-effects model, the hospital-wide (including ICU) pooled mortality odds ratio (OR) of patients with COVID-19 treated with TCZ was 0.73 (95% confidence interval (CI) = 0.56-0.93). The pooled hospital-wide mortality OR was 1.25 (95% CI = 0.74-2.18) in patients admitted at conventional wards versus 0.66 (95% CI = 0.59-0.76) in patients admitted to the ICU. The pooled OR of hospital-wide mortality (including ICU) of COVID-19 patients treated with TCZ plus corticosteroids (CS) was 0.67 (95% CI = 0.54-0.84). The pooled in-hospital mortality OR was 0.71 (95% CI = 0.35-1.42) when TCZ was early administered (≤10 days from symptom onset) versus 0.83 (95% CI 0.48-1.45) for late administration (>10 days from symptom onset). The meta-analysis did not find significantly higher risk for secondary infections in COVID-19 patients treated with TCZ. CONCLUSIONS TCZ prevented mortality in patients hospitalized for COVID-19. This benefit was seen to a greater extent in patients receiving concomitant CS and when TCZ administration occurred within the first 10 days after symptom onset.
Collapse
Affiliation(s)
- Manuel Rubio‐Rivas
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Carlos G. Forero
- School of MedicineUniversitat Internacional de CatalunyaBarcelonaSpain
| | - José María Mora‐Luján
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Abelardo Montero
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Francesc Formiga
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Narcís A. Homs
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Joan Albà‐Albalate
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Laura Sánchez
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
| | - Jordi Rello
- School of MedicineUniversitat Internacional de CatalunyaBarcelonaSpain
- Centro de Investigación Biomédica en Red (CIBERES)Instituto de Salud Carlos IIIMadridSpain
- CRIPSVall d’Hebrón Institute of ResearchBarcelonaSpain
| | - Xavier Corbella
- Department of Internal MedicineBellvitge University HospitalBellvitge Biomedical Research Institute‐IDIBELLUniversity of BarcelonaBarcelonaSpain
- School of MedicineUniversitat Internacional de CatalunyaBarcelonaSpain
| |
Collapse
|
8
|
Dravid A, Kashiva R, Khan Z, Memon D, Kodre A, Potdar P, Mane M, Borse R, Pawar V, Patil D, Banerjee D, Bhoite K, Pharande R, Kalyani S, Raut P, Bapte M, Mehta A, Reddy MS, Bhayani K, Laxmi SS, Vishnu PD, Srivastava S, Khandelwal S, More S, Shinde R, Pawar M, Harshe A, Kadam S, Mahajan U, Joshi G, Mane D. Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune, Western India. Medicine (Baltimore) 2021; 100:e26705. [PMID: 34398044 PMCID: PMC8294888 DOI: 10.1097/md.0000000000026705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/26/2021] [Accepted: 06/19/2021] [Indexed: 01/08/2023] Open
Abstract
ABSTRACT Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.
Collapse
Affiliation(s)
- Ameet Dravid
- Department of Infectious Diseases and HIV/AIDS, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Reema Kashiva
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Zafer Khan
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Danish Memon
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Aparna Kodre
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Prashant Potdar
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Milind Mane
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Rakesh Borse
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Vishal Pawar
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Dattatraya Patil
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Debashis Banerjee
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Kailas Bhoite
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Reshma Pharande
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Suraj Kalyani
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Prathamesh Raut
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Madhura Bapte
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Anshul Mehta
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - M. Sateesh Reddy
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Krushnadas Bhayani
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - S. S. Laxmi
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - P. D. Vishnu
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Shipra Srivastava
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Shubham Khandelwal
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Sailee More
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Rohit Shinde
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Mohit Pawar
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Amol Harshe
- Department of Pathology, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Sagar Kadam
- Department of Radiology, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Uma Mahajan
- VMK Diagnostics Private Limited, Pune, Maharashtra, India
| | | | - Dilip Mane
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| |
Collapse
|
9
|
SM Z, HH MZ, S T. Pneumocystis Jirovecii Pneumonia as a Sequela of COVID-19. JOURNAL OF BIOMEDICAL RESEARCH & ENVIRONMENTAL SCIENCES 2021:425-428. [DOI: 10.37871/jbres1253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
A 71 years old male came to the hospital with the complaint of cough and fever since 7 days. He was diagnosed with severe COVID pneumonia and was managed with steroids and tocilizumab. He was discharged on steroids and came after 20 days with complaints of worsening shortness of breath and hypoxia. Bronchoscopy and bronchoalveolar lavage was done which showed positive PCR for Pneumocystis Jirovecii Pneumonia (PCP). Patient was started on co-trimoxazole and steroids after which he showed remarkable improvement. This is one of the rare cases in which patient developed PCP as a sequelae of COVID-19.
Collapse
|
10
|
Almas A, Mushtaq Z, Moller J. Acuity level of care as a predictor of case fatality and prolonged hospital stay in patients with COVID-19: a hospital-based observational follow-up study from Pakistan. BMJ Open 2021; 11:e045414. [PMID: 34049912 PMCID: PMC8166477 DOI: 10.1136/bmjopen-2020-045414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19. DESIGN A hospital-based observational follow-up study. SETTING Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020. PARTICIPANTS Adult patients with confirmed COVID-19, aged ≥18 years. METHODS ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and length of stay. RESULTS A total of 822 patients with COVID-19 were admitted during the study period and 699 met inclusion criteria. The mean age was 54.5 years and 67% were males; 50.4% were triaged to low, 42.5% to intermediate and 7.2% to high acuity care. The overall case-fatality rate was 11.6%, with the highest (52%) in high acuity level followed by 16.2% in intermediate and 2% in low acuity care. Acuity level was associated with case fatality, with an HR (95% CI) of 5.0 (2.0 to 12.1) for high versus low acuity care and an HR of 2.7 (1.2, 6.4) for intermediate versus low acuity care, after adjusting for age, sex and common comorbidities including diabetes, hypertension, ischaemic heart disease and chronic lung disease. Similarly, acuity level was also associated with length of hospital stay. CONCLUSION High and intermediate acuity level is associated with higher case fatality rate and prolonged length of hospital stay in patients admitted with COVID-19. In resource-limited settings where the provision of high acuity care is limited, the intermediate care acuity could serve as a useful strategy to treat relatively less critical patients with COVID-19.
Collapse
Affiliation(s)
- Aysha Almas
- Medicine, Aga Khan University, Karachi, Pakistan
| | - Zain Mushtaq
- Medicine, Aga Khan University, Karachi, Pakistan
| | - Jette Moller
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
11
|
Ahsan T, Rani B, Siddiqui R, D'Souza G, Memon R, Lutfi I, I Hasan O, Javed R, Khan F, Hassan M. Clinical Variants, Characteristics, and Outcomes Among COVID-19 Patients: A Case Series Analysis at a Tertiary Care Hospital in Karachi, Pakistan. Cureus 2021; 13:e14761. [PMID: 34084685 PMCID: PMC8164449 DOI: 10.7759/cureus.14761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Coronavirus disease 2019 (COVID-19) has become a global threat to public health. The current study investigates alterations in the biological estimates concerning the severity, recovery, mortality, and assessment of treatment-based outcomes. Methods A case series of 165 COVID-19 patients admitted to OMI Institute (a tertiary care hospital) was conducted between May and August 2020. The data regarding demographic characteristics, comorbid conditions, radiographic abnormalities, biological estimations, symptoms, treatment, disease progression, complications, and outcomes were recorded using a structured questionnaire. Laboratory estimations included complete blood count (CBC), renal and electrolyte profile, liver function tests (LFTs), hematological indices, and inflammatory markers. Chest X-ray, electrocardiogram (ECG), and a high-resolution computed tomography (HRCT) scan were also performed, and data were extracted from the medical records. Analysis was done using the Statistical Package for the Social Sciences (SPSS) version 22.0. Results Out of the 165 COVID-19 patients, 79.4% recovered and were successfully discharged, while 20.6% of inpatient died. The patients' mean age was 56.03 ± 15.96 years, with a male majority (55.1%). The most common comorbid conditions were diabetes and hypertension; fever and dry cough were among the most frequently reported symptoms. The chest imaging findings among the severe/critical COVID-19 patients showed extensive bilateral patchy opacities. The median laboratory investigations, including neutrophil-to-lymphocyte ratio (NLR) (14.83), C-reactive protein (CRP) (7.4 mg/dl), lactate dehydrogenase (LDH) (786 IU/L), ferritin (1401.15 mcg/ml), and mean oxygen saturation (88.25%), were significantly altered among cases with increased disease severity and those who expired (p<0.05). The proportion of acute respiratory distress syndrome (ARDS) and sepsis development was significantly high among severe/critical COVID-19 patients (p<0.05). Treatment with tocilizumab, remdesivir, doxycycline, ivermectin, enoxaparin sodium, and steroids was deemed to be potentially effective treatment options in terms of reducing COVID-19 severity and chances of recovery. Furthermore, age (OR 1.05; p=0.047), presence of comorbidity (OR 8.471; p=0.004), high NLR, LDH (final outcome) (OR 1.361 and 1.018; p<0.05), and CRP levels (midpoint) (OR 1.631; p=0.05) were identified as the strong predictors of death among COVID-19 patients. Conclusion The study identified several alterations in the clinical profile of the COVID-19 patients concerning severity during the hospital stay, affecting prognosis. Clinically, tocilizumab, remdesivir, doxycycline, ivermectin, enoxaparin sodium, and steroids were identified as potential therapeutic options for COVID-19 due to their ability to alter disease-associated severity and recovery rate.
Collapse
Affiliation(s)
- Tasnim Ahsan
- Internal Medicine: Diabetes & Endocrinology, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | - Bharta Rani
- Internal Medicine, Diabetes and Endocrinology, Jinnah Postgraduate Medical Centre, Medicell Institute of Diabetes Endocrinology & Metabolism (MIDEM), Karachi, PAK
| | | | | | | | - Irfan Lutfi
- Interventional Radiology, Shaheed Mohtarma Benazir Bhutto Medical College, Dow University of Health Sciences, Karachi, PAK
| | | | | | - Farhan Khan
- Internal Medicine, OMI Institute, Karachi, PAK
| | | |
Collapse
|
12
|
Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan. Epidemiol Infect 2021; 149:e37. [PMID: 33468267 PMCID: PMC7873461 DOI: 10.1017/s095026882100011x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5-10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8-25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.
Collapse
|
13
|
Abers MS, Delmonte OM, Ricotta EE, Fintzi J, Fink DL, de Jesus AAA, Zarember KA, Alehashemi S, Oikonomou V, Desai JV, Canna SW, Shakoory B, Dobbs K, Imberti L, Sottini A, Quiros-Roldan E, Castelli F, Rossi C, Brugnoni D, Biondi A, Bettini LR, D’Angio’ M, Bonfanti P, Castagnoli R, Montagna D, Licari A, Marseglia GL, Gliniewicz EF, Shaw E, Kahle DE, Rastegar AT, Stack M, Myint-Hpu K, Levinson SL, DiNubile MJ, Chertow DW, Burbelo PD, Cohen JI, Calvo KR, Tsang JS, Su HC, Gallin JI, Kuhns DB, Goldbach-Mansky R, Lionakis MS, Notarangelo LD. An immune-based biomarker signature is associated with mortality in COVID-19 patients. JCI Insight 2021; 6:144455. [PMID: 33232303 PMCID: PMC7821609 DOI: 10.1172/jci.insight.144455] [Citation(s) in RCA: 233] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/18/2020] [Indexed: 12/25/2022] Open
Abstract
Immune and inflammatory responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contribute to disease severity of coronavirus disease 2019 (COVID-19). However, the utility of specific immune-based biomarkers to predict clinical outcome remains elusive. Here, we analyzed levels of 66 soluble biomarkers in 175 Italian patients with COVID-19 ranging from mild/moderate to critical severity and assessed type I IFN-, type II IFN-, and NF-κB-dependent whole-blood transcriptional signatures. A broad inflammatory signature was observed, implicating activation of various immune and nonhematopoietic cell subsets. Discordance between IFN-α2a protein and IFNA2 transcript levels in blood suggests that type I IFNs during COVID-19 may be primarily produced by tissue-resident cells. Multivariable analysis of patients' first samples revealed 12 biomarkers (CCL2, IL-15, soluble ST2 [sST2], NGAL, sTNFRSF1A, ferritin, IL-6, S100A9, MMP-9, IL-2, sVEGFR1, IL-10) that when increased were independently associated with mortality. Multivariate analyses of longitudinal biomarker trajectories identified 8 of the aforementioned biomarkers (IL-15, IL-2, NGAL, CCL2, MMP-9, sTNFRSF1A, sST2, IL-10) and 2 additional biomarkers (lactoferrin, CXCL9) that were substantially associated with mortality when increased, while IL-1α was associated with mortality when decreased. Among these, sST2, sTNFRSF1A, IL-10, and IL-15 were consistently higher throughout the hospitalization in patients who died versus those who recovered, suggesting that these biomarkers may provide an early warning of eventual disease outcome.
Collapse
Affiliation(s)
- Michael S. Abers
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Ottavia M. Delmonte
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Emily E. Ricotta
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jonathan Fintzi
- Biostatistics Research Branch, NIAID, NIH, Bethesda, Maryland, USA
| | - Danielle L. Fink
- Neutrophil Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Adriana A. Almeida de Jesus
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Kol A. Zarember
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Sara Alehashemi
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Vasileios Oikonomou
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jigar V. Desai
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Scott W. Canna
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bita Shakoory
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Luisa Imberti
- CREA Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessandra Sottini
- CREA Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Eugenia Quiros-Roldan
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy
| | - Francesco Castelli
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy
| | - Camillo Rossi
- Direzione Sanitaria, ASST Spedali Civili di Brescia, Italy
| | - Duilio Brugnoni
- Laboratorio Analisi Chimico-Cliniche, ASST Spedali Civili, Brescia, Italy
| | - Andrea Biondi
- Pediatric Department and Centro Tettamanti-European Reference Network on Paediatric Cancer, European Reference Network on Haematological Diseases, and European Reference Network on Hereditary Metabolic Disorders-University of Milano-Bicocca-Fondazione MBBM, Monza, Italy
| | - Laura Rachele Bettini
- Pediatric Department and Centro Tettamanti-European Reference Network on Paediatric Cancer, European Reference Network on Haematological Diseases, and European Reference Network on Hereditary Metabolic Disorders-University of Milano-Bicocca-Fondazione MBBM, Monza, Italy
| | - Mariella D’Angio’
- Pediatric Department and Centro Tettamanti-European Reference Network on Paediatric Cancer, European Reference Network on Haematological Diseases, and European Reference Network on Hereditary Metabolic Disorders-University of Milano-Bicocca-Fondazione MBBM, Monza, Italy
| | - Paolo Bonfanti
- Department of Infectious Diseases, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | | | - Daniela Montagna
- Laboratory of Immunology and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | | | | | - Emily F. Gliniewicz
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Elana Shaw
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Dana E. Kahle
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Andre T. Rastegar
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Michael Stack
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Katherine Myint-Hpu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | | | | | - Daniel W. Chertow
- Critical Care Medicine Department, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Peter D. Burbelo
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, Maryland, USA
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Katherine R. Calvo
- Hematology Section, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - John S. Tsang
- Laboratory of Immune System Biology and Clinical Genomics Program, NIAID, NIH, Bethesda, Maryland, USA
- Center for Human Immunology, Autoimmunity, and Inflammation, NIAID, NIH, Bethesda, Maryland, USA
| | | | - Helen C. Su
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - John I. Gallin
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Douglas B. Kuhns
- Neutrophil Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Raphaela Goldbach-Mansky
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Michail S. Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| |
Collapse
|
14
|
Perrone F, Piccirillo MC, Ascierto PA, Salvarani C, Parrella R, Marata AM, Popoli P, Ferraris L, Marrocco-Trischitta MM, Ripamonti D, Binda F, Bonfanti P, Squillace N, Castelli F, Muiesan ML, Lichtner M, Calzetti C, Salerno ND, Atripaldi L, Cascella M, Costantini M, Dolci G, Facciolongo NC, Fraganza F, Massari M, Montesarchio V, Mussini C, Negri EA, Botti G, Cardone C, Gargiulo P, Gravina A, Schettino C, Arenare L, Chiodini P, Gallo C. Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial. J Transl Med 2020; 18:405. [PMID: 33087150 PMCID: PMC7576974 DOI: 10.1186/s12967-020-02573-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients. METHODS A multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival. RESULTS In the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6-24.0, P = 0.52) and 22.4% (97.5% CI: 17.2-28.3, P < 0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline. CONCLUSIONS Tocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline. Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092).
Collapse
Affiliation(s)
- Francesco Perrone
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Maria Carmela Piccirillo
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Paolo Antonio Ascierto
- grid.508451.d0000 0004 1760 8805Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Carlo Salvarani
- grid.7548.e0000000121697570Rheumathology, Università degli Studi di Modena e Reggio Emilia and Azienda USL-IRCCS di Reggio Emilia, Modena, Italy
| | | | | | - Patrizia Popoli
- grid.416651.10000 0000 9120 6856Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Roma, Italy
| | - Laurenzia Ferraris
- grid.419557.b0000 0004 1766 7370Infectious Diseases Unit, Hospital Health Direction, IRCCS - Policlinico San Donato, Milano Milano, Italy
| | | | - Diego Ripamonti
- grid.460094.f0000 0004 1757 8431Infectious Diseases Unit - ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Binda
- grid.460094.f0000 0004 1757 8431Infectious Diseases Unit - ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Bonfanti
- grid.7563.70000 0001 2174 1754Infectious Diseases Unit, ASST Monza and University Milano Bicocca, Milan, Italy
| | - Nicola Squillace
- grid.7563.70000 0001 2174 1754Infectious Diseases Unit, ASST Monza and University Milano Bicocca, Milan, Italy
| | - Francesco Castelli
- grid.7637.50000000417571846University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Maria Lorenza Muiesan
- grid.7637.50000000417571846University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Miriam Lichtner
- grid.7841.aSapienza University of Rome, Santa Maria Goretti Hospital, Latina, Italy
| | - Carlo Calzetti
- Infectious Diseases and Hepatology Unit AOU, Parma, Italy
| | - Nicola Duccio Salerno
- grid.411475.20000 0004 1756 948XUOC Malattie Infettive e Tropicali, AOUI, Verona, Italy
| | | | - Marco Cascella
- grid.508451.d0000 0004 1760 8805Anesthesia and Resuscitation Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | | | - Giovanni Dolci
- grid.7548.e0000000121697570Rheumathology, Università degli Studi di Modena e Reggio Emilia and Azienda USL-IRCCS di Reggio Emilia, Modena, Italy
| | | | | | - Marco Massari
- Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Cristina Mussini
- grid.7548.e0000000121697570Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | | | - Gerardo Botti
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Claudia Cardone
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Piera Gargiulo
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Adriano Gravina
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Clorinda Schettino
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Laura Arenare
- grid.508451.d0000 0004 1760 8805Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Paolo Chiodini
- grid.9841.40000 0001 2200 8888Department of Mental Health and Preventive Medicine, Università degli Studi della Campania Luigi Vanvitelli, Caserta, Italy
| | - Ciro Gallo
- grid.9841.40000 0001 2200 8888Department of Mental Health and Preventive Medicine, Università degli Studi della Campania Luigi Vanvitelli, Caserta, Italy
| | | |
Collapse
|
15
|
Zhao M, Lu J, Tang Y, Dai Y, Zhou J, Wu Y. Tocilizumab for treating COVID-19: a systemic review and meta-analysis of retrospective studies. Eur J Clin Pharmacol 2020; 77:311-319. [PMID: 33051695 PMCID: PMC7553373 DOI: 10.1007/s00228-020-03017-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES COVID-19 has become a global epidemic, and effective therapies have not been discovered up to now. We conducted this study to explore the effectiveness and safety of tocilizumab recently used for treating COVID-19. METHOD A comprehensive search was conducted (up to September 27, 2020), and 19 eligible records were identified according to the inclusion and exclusion criteria. The data of the studies were extracted by 2 independent reviewers and were analyzed to evaluate the safety and availability of tocilizumab for treating COVID-19. RESULTS Thirteen retrospective case-control studies (n = 2285 patients) and 6 retrospective single-armed studies (n = 208) were retrieved in this study. In the comparison of tocilizumab treatment group (TCZ) and standard treatment group (ST), significant associations with a lower risk of admission to ICU, use of ventilation, and mortality (OR, 95% CI: 0.53, 0.26~1.09; 0.66, 0.46~0.94; 0.44, 0.36~0.55) were found in the tocilizumab treatment group. What is more, patients treated with tocilizumab had better clinical improvement compared with the patients treated with ST (OR, 1.24; 95% CI, 0.96~1.62). After taking tocilizumab, the patients had lower C-reactive protein (CRP), white blood cell count (WBC), aspartate aminotransferase (AST) (WMD, 95% CI: - 99.66, - 156.24~- 43.09; - 0.95, - 1.8~- 0.11; - 12.58, - 18.88~-6.29) but higher troponin (WMD, 7.61; 95% CI, 3.06~12.15) than before. In addition, tocilizumab did not have significant influence on patients' neutrophil count (Neut), lymphocyte count (Lymp), platelet count (Plt), alanine aminotransferase (ALT), and creatine (WMD, 95% CI: - 0.29, - 2.91~2.33; 0.42, - 0.23~1.07; 5.2, - 2.85~13.25; 22.49, - 2.73~47.7; - 44.78, - 93.37~3.81). CONCLUSION Tocilizumab may have potential effectiveness to treat COVID-19 according to the results of this study. However, more large-scale studies are needed for more accurate conclusions.
Collapse
Affiliation(s)
- Meng Zhao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Jieyu Lu
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yihu Tang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Yawei Dai
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Jingxin Zhou
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China.
| | - Yanhu Wu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China.
| |
Collapse
|