Purpose of review To review and compare the constellations of causes and consequences of the two current pandemics, Covid-19 and climate change. Recent findings There has been a transient counterbalancing, in which the response to Covid-19 has briefly mitigated pollution and greenhouse gasses. This divergence belies multiple commonalities of cause and effect. Summary The convergence of these two pandemics is unprecedented. Although at first glance, they appear to be completely unrelated, they share striking commonalities. Both are caused by human behaviors, and some of those behaviors contribute to both pandemics at the same time. Both illustrate the fact that isolation is not an option; these are global issues that inescapably affect all persons and all nations. Both incur prodigious current and anticipated costs. Both have similar societal impacts, and disproportionately harm those with lesser resources, widening the gap between the ‘haves and the have-nots.’ One can only hope that the devastation caused by these unprecedented pandemics will lead to increased awareness of how human beings have helped to create them and how our responses can and will shape our future.
Research QuestionDoes treatment with tocilizumab increase the risk of a fungal infection in critically ill patients with coronavirus-19?BackgroundNumerous therapies have been re-evaluated as possible treatment options for coronavirus-2019 caused by severe acute respiratory syndrome coronavirus-2. Tocilizumab is a humanized monoclonal antibody directed against the interleukin-6 receptor that has been proposed as a therapy for patients with severe coronavirus-19 pneumonia. The immunomodulatory effects of tocilizumab may have the unintended consequence of predisposing recipients to secondary infections. We sought to assess the risk of invasive fungal disease and the therapeutic impact of tocilizumab on hospital length of stay, duration of mechanical ventilation, and intensive care unit length of stay in critically ill patients with severe coronavirus-19.MethodsRecords of critically ill patients with coronavirus-2019 admitted from March to September 2020 at our institution were reviewed. The risk for fungal infections, intensive care unit length of stay, hospital length of stay, and duration of mechanical ventilation in those that received tocilizumab in addition to standard coronavirus-2019 treatments was assessed. ResultsFifty-six critically ill patients treated with dexamethasone and remdesivir for coronavirus-2019 were included, of which 16 patients also received tocilizumab. The majority of the cohort was African American, Asian, or other ethnic minorities (53.6%). Invasive fungal infections occurred in 10.7% of all patients and infection rates were significantly higher in the tocilizumab group than in the control group (31.2% vs 2.5%, Risk Difference [RD]= 28.8%, p<0.01). The increased risk in the tocilizumab group was strongly associated with renal replacement therapy. There was a dose-response relation between the risk of fungal infection and doses of tocilizumab, with 2.5% of infections occurring with zero doses, 20% with a single dose (RD=17.5%), and 50% with two doses (RD=47.5%) (trend test p<0.001). In addition, ICU LOS (23.4 days v 9.0 days, p <0.01), duration of mechanical ventilation (18.9 v. 3.5 days, p=0.01), and hospital LOS (29.1 v. 15.5, p <0.01) were increased in patients that received tocilizumab. ConclusionsRepurposed therapies, such as tocilizumab, may have a role in the treatment of severe coronavirus-2019 pneumonia but safety concerns remain. In this cohort, tocilizumab treatment was associated with an increased risk of fungal infection in those that were critically ill and received renal replacement therapy. Tocilizumab was also associated with increased ICU and hospital LOS and duration of mechanical ventilation.
INTRODUCTION:Tacrolimus is commonly used for immunosuppression after solid-organ transplant to prevent organ rejection. Tacrolimus has a wide range of adverse effects, including secondary infections, renal failure, hyperglycemia, and weight gain, when used in combination with other immunosuppression medications. However, association with diffuse lung disease is quite rare. We present a case of diffuse lung injury associated with tacrolimus. CASE PRESENTATION:A 56-year-old Caucasian man with a past medical history of hypertension, diabetes, morbid obesity, renal transplant on tacrolimus and mycophenolate, and localized renal cell carcinoma with nephrectomy was transferred to our institution for evaluation of suspected non-small cell lung cancer (NSCLC). A few weeks prior to the current presentation, the patient was diagnosed and treated for community-acquired pneumonia with oral antibiotics. Follow-up imaging, with CT Chest and subsequent PET CT, revealed diffuse interstitial changes with multiple small pulmonary nodules without increased metabolic activity concerning for lymphangitic carcinomatosis or atypical infection. During PET CT, the patient became hypoxic and was admitted. Bronchoscopy with brush biopsy and BAL demonstrated atypical cells concerning for NSCLC, and the patient was transferred to our institution for further evaluation. Due to inconclusive pathology report from prior bronchoscopy, persistent hypoxia, and dyspnea on exertion, the patient underwent repeat bronchoscopy with endobronchial ultrasound-guided biopsy, BAL, and trans-bronchial biopsies, which was negative for malignancy. Extensive microbiologic workup for viral, bacterial, and fungal organisms remained negative. BAL differential showed significant eosinophilia of 15%, and transbronchial biopsy showed acute on chronic inflammation. Drug toxicity secondary to tacrolimus was presumed to be the primary culprit. The patient was started on prednisone therapy and discharged. On outpatient follow-up six weeks later, the patient had resolution of dyspnea, and repeat imaging demonstrated complete resolution of interstitial opacities. Tacrolimus was discontinued indefinitely.DISCUSSION: Tacrolimus is commonly used for immunosuppression after solid organ transplantation to prevent organ rejection. The association of Tacrolimus with interstitial lung disease is quite rare and previously described in a case series of rheumatoid arthritis patients. To the best of our knowledge, this is the first description of tacrolimus-induced interstitial lung disease in renal transplant patients.CONCLUSIONS: Tacrolimus-associated diffuse lung disease, although rare, should be considered in patients presenting with diffuse infiltrates while on this therapy, after appropriate work up to exclude infections.
Research Question: Does treatment with tocilizumab increase the risk of a fungal infection in critically ill patients with coronavirus-19? Background: Numerous therapies have been evaluated as possible treatments for coronavirus-2019 caused by severe acute respiratory syndrome coronavirus-2. Tocilizumab is a humanized monoclonal antibody directed against the interleukin-6 receptor that has found a role as a therapy for patients with severe coronavirus-19 pneumonia. The immunomodulatory effects of tocilizumab may have the unintended consequence of predisposing recipients to secondary infections. We sought to assess the risk of invasive fungal disease and the therapeutic impact of tocilizumab on the hospital length of stay, duration of mechanical ventilation, and intensive-care-unit length of stay in critically ill patients with severe coronavirus-19 pneumonia. Methods: Records of critically ill patients with coronavirus-2019 admitted from March to September 2020 at our institution were reviewed. The risk for fungal infections, intensive-care-unit length of stay, hospital length of stay, and duration of mechanical ventilation in those that received tocilizumab in addition to standard coronavirus-2019 treatments was assessed. Results: Fifty-six critically ill patients treated with dexamethasone and remdesivir for coronavirus-2019 were included, of which 16 patients also received tocilizumab. The majority of the cohort was African American, Asian, or of other ethnic minorities (53.6%). Invasive fungal infections occurred in 10.7% of all patients, and infection rates were significantly higher in the tocilizumab group than in the control group (31.2% vs. 2.5%, risk difference [RD] = 28.8%, p < 0.01). The increased risk in the tocilizumab group was strongly associated with renal replacement therapy. There was a dose–response relationship between the risk of fungal infection and number of tocilizumab doses received, with 2.5% of infections occurring with zero doses, 20% with a single dose (RD = 17.5%), and 50% with two doses (RD = 47.5%) (trend test p < 0.001). In addition, ICU LOS (23.4 days vs. 9.0 days, p < 0.01), the duration of mechanical ventilation (18.9 vs. 3.5 days, p = 0.01), and hospital length of stay (LOS) (29.1 vs. 15.5, p < 0.01) were increased in patients that received tocilizumab. Conclusions: Repurposed immunomodulator therapies, such as tocilizumab, are now recommended treatments for severe coronavirus-2019 pneumonia, but safety concerns remain. In this early pandemic cohort, the addition of tocilizumab to dexamethasone was associated with an increased risk of fungal infection in those that were critically ill and received renal replacement therapy. Tocilizumab use was also associated with increased ICU and hospital LOSs and duration of mechanical ventilation.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.