RESUMO
A 59-year-old male patient was admitted to hospital diagnosed with moderate pneumonia associated with COVID-19. Upfront treatment with hydroxychloroquine and azithromycin was started. Due to a clinical deterioration (ARDS, circulatory shock) and greatly increased inflammation markers 6 days after admission, a cytokine storm was suspected and off-label treatment with the IL6 receptor antagonist tocilizumab was initiated. Subsequently there was a dramatic rise of Ddimers indicating pulmonary intravascular coagulopathy and respiratory insufficiency worsened. After a second dose of tocilizumab was administered severe perimyocarditis with cardiac arrhythmia, hemodynamic instability and ST elevation occurred. Shortly afterwards the patient died due to multiorgan failure. From our experience, exacerbation of COVID-19 following treatment with tocilizumab cannot be ruled out. Randomized controlled studies are necessary to further investigate the efficacy, safety and patient selection criteria for tocilizumab treatment in COVID-19.
Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Anticorpos Monoclonais Humanizados/uso terapêutico , Antivirais/efeitos adversos , Antivirais/uso terapêutico , Transtornos da Coagulação Sanguínea/etiologia , Tratamento Farmacológico da COVID-19 , Síndrome da Liberação de Citocina/tratamento farmacológico , Miocardite/etiologia , Receptores de Interleucina-6/antagonistas & inibidores , Evolução Fatal , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Uso Off-Label , Síndrome do Desconforto Respiratório/etiologia , Insuficiência Respiratória , Resultado do TratamentoRESUMO
HISTORY AND CLINICAL FINDINGS: A 70-year-old female patient developed a non-pruritic, indolent rash associated with infections and peripheral blood abnormalities. A skin biopsy was suggestive of malignant lymphoma of the skin. INVESTIGATIONS: The peripheral blood count showed mild pancytopenia and 12 % blasts. Additional immunohistochemistry of the skin specimen as well as cytologic and flow cytometric examination of the bone marrow revealed an immature cell population expressing CD4 and CD56 which infiltrated both the dermis and, with an infiltration grade of about 85 %, the bone marrow. DIAGNOSIS: Blastic plasmacytoid dendritic cell neoplasm (formerly known as blastic NK cell lymphoma). TREATMENT AND COURSE: After the first course of induction chemotherapy with daunorubicin and cytarabin, both the rash and the hematologic findings of bone marrow and peripheral blood showed a complete remission. CONCLUSION: The blastic plasmacytoid dendritic cell neoplasm is a rare, aggressive hematopoietic neoplasm most likely related to acute myeloid leukemia (AML). Since cutaneous involvement is regularly present at diagnosis, the differential diagnosis of unexplained skin lesions should include this disease entity, especially if peripheral blood abnormalities are present. Despite the initial response to cytostatic therapy being mostly excellent, the prognosis is poor. Hence, treatment as high-risk AML seems advisable.