Ileal perforation in a tocilizumab-treated patient with rheumatoid arthritis in SARS-CoV- 2 infection

ABSTRACT

Introduction: Tocilizumab, a monoclonal anti-interleukin- 6 receptor antibody, has been widely used as a treatment for rheumatoid arthritis. Gastrointestinal perforation is a rare but critical complication that occurs in patients treated with tocilizumab. In the COVID-19 pandemic, tocilizumab has been recently highlighted for its beneficial effect in reducing the risk of death in severely ill COVID-19 patients. In this current study, we report the ileal perforation in a COVID-19 confirmed patient who had received tocilizumab for the treatment of rheumatoid arthritis. Case Presentation A 57-year- old woman with a medical history of rheumatoid arthritis and hypertension presented to our emergency room with abrupt onset of severe abdominal pain and nausea. Physical examination revealed direct and indirect tenderness of the whole abdomen. She had a history of COVID-19 infection 1 month ago and recovered without severe complications. She also has been treated for rheumatoid arthritis, and the disease activity has been maintained low with the administration of tocilizumab since 2019. The latest administration of tocilizumab to the patient was 2 weeks ago. The plain radiograph of the abdomen showed intraperitoneal free air suggesting pneumoperitoneum. The abdominal computed tomography was also conducted to find the origin of free extraluminal air, and it revealed heterogenous wall enhancement of the ileal loop and the mesenteric haziness. The emergency surgery was performed, and the ileal perforation was noted. The small bowel segmental resection was performed through the surgical procedure. Conclusion(s) COVID-19 has been founded to cause gastrointestinal inflammation. The use of tocilizumab in COVID-19 patients should be carefully conducted because it could act as a permissive of gastrointestinal perforation. Furthermore, the physician should be aware of the possible complication of tocilizumab because early diagnosis and timely management are crucial to preventing high mortality complications.