Hemophagocytic lymphohistiocytosis in a patient with COVID-19 treated with tocilizumab: a case report

• Published in: Journal of medical case reports 2020-10, Vol.14 (1), p.187-187, Article 187
• Main Authors: Tholin, Birgitte, Hauge, Marit Teigen, Aukrust, Pål, Fehrle, Lutz, Tvedt, Tor Henrik
• Format: Article
• Language: English
• Subjects: Age; Aged; Antibodies, Monoclonal - administration & dosage; Antibodies, Monoclonal, Humanized - administration & dosage; B cells; Betacoronavirus - isolation & purification; C-reactive protein; C-Reactive Protein - analysis; Care and treatment; Case Report; Case reports; Coronavirus Infections - blood; Coronavirus Infections - complications; Coronavirus Infections - diagnosis; Coronavirus Infections - therapy; Coronaviruses; COVID-19; Cytokines; Drug dosages; Enzymes; Ferritin; Ferritins - blood; Fever; Guillain-Barre syndrome; Health aspects; Hemophagocytic lymphohistiocytosis; HLH; Humans; IL-6; Immunology; Immunosuppressive agents; Infections; Inflammation - blood; Interleukin-6 - analysis; Interleukin-6 - antagonists & inhibitors; Interleukins; Laboratories; Lymphatic diseases; Lymphohistiocytosis, Hemophagocytic - etiology; Male; Monoclonal antibodies; Oxygen saturation; Pandemics; Patients; Pneumonia, Viral - blood; Pneumonia, Viral - complications; Pneumonia, Viral - diagnosis; Pneumonia, Viral - therapy; Respiration, Artificial - methods; Respiratory failure; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2; Tocilizumab; Treatment Outcome; Triglycerides; Tumor necrosis factor-TNF; Viral infections
• ISSN: 1752-1947; 1752-1947
• DOI: 10.1186/s13256-020-02503-9

The understanding of coronavirus disease 2019 (COVID-19) is rapidly evolving. Although it is primarily a respiratory illness, other manifestations, such as Guillain-Barré syndrome, immune thrombocytopenia, and immune-mediated thrombotic thrombocytopenic purpura, have been described. We present a case of a patient with hemophagocytic lymphohistiocytosis secondary to COVID-19 treated with tocilizumab with a marked biochemical improvement. In this case report we present a Caucasian patient with COVID-19 who developed a marked elevation of inflammatory parameters with ferritin 36,023 μg/L, but also elevated C-reactive protein 334 mg/L and lactate dehydrogenase 1074 U/L, 1 week after admission to the intensive care unit. He met five of eight criteria for hemophagocytic lymphohistiocytosis, but he lacked the high fever and cytopenia seen in the majority of cases. He was treated with tocilizumab, a monoclonal antibody targeting the interleukin-6 receptor, and over the next days, a rapid decrease in ferritin and C-reactive protein levels was observed. However, his respiratory failure only improved gradually, and he was weaned off the respirator 11 days later. COVID-19 may induce a hyperinflammatory clinical picture and in some cases develop into hemophagocytic lymphohistiocytosis. In our patient's case, therapeutic interleukin-6 blockade abrogated signs of hyperinflammation but did not seem to improve pulmonary function. Measurement of ferritin and C-reactive protein, as well as quantification of interleukin-6 on indication, should be performed in patients with severe COVID-19. Specific treatment in such patients must also be contemplated, preferably in randomized controlled trials.