Early tocilizumab therapy in severe COVID, boon or a bane: A case report and critical appraisal

Introduction: Pneumonia with severe respiratory failure represents the principal cause of death in COVID-19, where hyper-inflammation plays an important role in lung damage An effective treatment aiming at reducing the inflammation without preventing virus clearance is thus urgently needed Tocilizumab, an anti-IL-6 receptor monoclonal antibody, has been proposed for the treatment of patients with COVID-19 Early use of tocilizumab prevents sudden deterioration of patient but after 15 days cavitary lesions are found in HRCT chest which is manageable Objectives: To discuss the use of early tocilizumab in severe COVID pneumonia patients Materials and methods: A 46-year-old Indian man presented in casualty with the complaint of shortness of breath, cough fever since 5 days admitted in COVID ward after COVID-19 RT-PCR tested positive HRCT chest shows 90% lung involvement The initial patient was vitally stable with SpO2 98 with 15 L oxygen support NRBM, respiratory rate was 18/minute ABG shows mild hypoxia On day 2, the patient started deteriorating, not maintaining saturation on NRNM support taking on NIV support Worsening of blood marker started We plan for use of early tocilizumab 400 mg The next day tocilizumab was given The patient intubated and took on AC/VC support After 5 days, the patient successfully extubated On the seventh day, the patient extubate Results: Use of early tocilizumab prevents sudden deterioration of patient with 90% lung involvement but after 20 days cavitary lesions found which is manageable Discussions: The patient came with severe pneumonia due to COVID Tocilizumab was given on the third day of admission The blood marker shows regular improvement The patient intubated then extubated Cavitary lesion developed Oxygen requirement slowly decreases Bronchoscopy shows normal findings BAL shows tubercular etiology ATT started After 30 days, the patient successfully discharge Conclusion: Tocilizumab can be beneficial to the suddenly deteriorating patients due to hyperimmune reaction if the timing of administration is right