ELDERLY PERSON WITH COVID-19 AND SEVERE ARDS WITH PROLONGED ACTIVE VIRAL REPLICATION AND DOUBLE RESURGENCE OF CYTOKINE STORM TREATED WITH SOTROVIMAB AND CASIRIVIMAB/IMDEVIMAB

ABSTRACT

SESSION TITLE Global Case Reports in Critical Care SESSION TYPE Global Case Reports PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: Our world has been ravaged by SARS-COV2 over 2 years resulting in mortality in excess of six million lives. More insights have been known in lights of pathophysiology, natural history and modalities of therapy. Cytokine release syndrome, as one of the most dreadful consequences after acute COVID-19 infection, can lead to severe ARDS and deaths. Typically, CRS happens in the first 5-10 days after the initial date on infection. Multiple modes of treatments have been proposed and become standard of care for this life-threatening condition. CASE PRESENTATION 86 -year-old female with CAD, HTN, SSS, dementia developed 3-day history of fever with dyspnea (SpO2 75% on ambient air). COVID vaccine history was AZ, AZ and Moderna 1 month ago. She was admitted to ICU and placed on oxygen high flow FiO2 50%. She was promptly started on IV Remdesivir, Dexamethasone and Tocilizumab. Then, SARS-COV2 Omicron strain had dominated Thailand reaching almost 99%. Thus, she was given IV Sotrovimab. She gradually improved and was able to wean off from oxygen high flow. As we anticipate transferring her out of ICU once the RT-PCR for COVID-19 reached the safety threshold, those subsequent PCR tests have been in the range of active replication of virus. On ICU day 24, her condition deteriorated with fever spike and more dyspnea needed the use of O2 NHF once again. Studies had revealed that more virus replication and cytokine storm had resumed as evidenced by rising CRP and IL-6 level. This moment, we suspected that she could have contracted a Delta strain. Therefore, we decided to give IV Casirivimab/Imdevimab along with Dexamethasone for this second CRS. NP swab had been sent to Thai genomics lab to identify the virus strain. This time, she gradually recovered over 7 days. Finally, the RT-PCR on day 31 had been in the safe zone and she was discharged home. Subsequent result from genomic study had confirmation of Omicron strain of the COVID-19. DISCUSSION: Typically, cytokine storm after COVID-19 pneumonia happens within 7-10 days after the onset of infection. Without appropriate treatments, this can result in severe pneumonia/ARDS and eventual death. To our knowledge, after the successful treatment of the first wave of CRS, the patient should either recover gradually or succumb to the severe systemic effects. This case has highlighted that there can be a second wave of cytokine storm especially if the virus continued to replicate even with appropriate therapies. Repeated dose of antiviral drugs and possible a different kind of monoclonal antibody might come into role and can potentially save life in this uncommon event. CONCLUSIONS: We report an interesting case of CRS resulting in severe ARDS with unusually prolonged active viral replication despite of treatments. More surprisingly, this patient also had developed a double resurgence of cytokine storm from this particularly sustained viral replication. Reference #1 1. David C. Fajgenbaum, M.D., and Carl H. June, M.D. Cytokine Storm N Engl J Med 2020;3832255-2273 DOI 10.1056/NEJMra2026131 Reference #2 2. Yujun Tang, Jiajia Liu, […], and Chengping Wen Cytokine Storm in COVID-19 The Current Evidence and Treatment Strategies Front Immunol 2020;111708 DISCLOSURES No relevant relationships by Kasem Sirithanakul