Clinical course of severe COVID19 treated with tocilizumab and antivirals post‐allogeneic stem cell transplant with extensive chronic GVHD

Abstract

Although majority of cases with SARS COV-2 infection have mild symptoms or are asymptomatic, 10% patients have a severe disease. 1 As of 10th January 2021, according to current WHO data, there are 88 million cases worldwide, with 2.1% mortality rate. 2 A study from China which analysed 1590 COVID patients across 575 hospitals, showed that cancer patients are at higher risk of developing SARS-CoV-2 infection, and five times more likely to develop severe events such as use of mechanical ventilator, and death, compared to non-cancer patients. 3 Amongst cancer patients, those with hematological malignancies, who undergo HSCT and develop complications like GVHD, are even more susceptible to death from COVID-19 because of profound immunosuppression. 4 There is paucity of literature on COVID-19 in HSCT. We describe here the course and outcome of a patient who, after HSCT (complicated with extensive chronic GVHD including lung), developed severe COVID-19 and recovered completely.

Outcomes of COVID-19 in Hematopoietic Stem Cell Transplant Recipients: Multicenter Retrospective Analysis

“…Mirgh. S et al reported a case of an elderly patient post HSCT, who received tocilizumab and recovered whereas in our study cohort only 2 patients received tocilizumab (below 60 years) and both died within 28 days of SARS COV-2 infection [15].…”

“…1 Overall survival probability for severe COVID-19 infection versus mild ? moderate COVID-19 infection Indian J Hematol Blood Transfus intravenous therapies where possible, and postponing stem cell transplant procedures to a more favourable time have all been considered to reduce the risk of patient exposure to the viral infection [15].…”

Dilemma of Tocilizumab therapy for a patient with critical COVID‐19 disease and neutropenia: Case report and review of the literature

“…However, published data showed that tocilizumab was used in treating severe disease in patients with utmost risk of immunosuppression including hematological malignancies and post Allogenic Hematopoietic Stem Cell Transplant with favorable and safe outcome. 17,18 Similarly, its utility in cancer patients (including those who are actively receiving chemotherapy) was reported and suggests its safe administration even among neutropenic patient's subset 19,20 In clinical practice, the golden ethical advice is to observe patient's autonomy while implementing the principles beneficence and doing no harm. 21 Following discussion with the patients, balancing benefits against risks, the clinical team decided to administer Tocilizumab therapy under monitoring then salvage the critical neutropenia with G-CSF (filgrastim) to stimulate neutrophil production to safe outcome and recovery.…”

“…Despite the established management protocols and guidelines for severe COVID‐19 severe diseases among different patients’ categories, immunocompromised patients are often not included clinical trials making the clinical experience in immunocompromised hosts limited. However, published data showed that tocilizumab was used in treating severe disease in patients with utmost risk of immunosuppression including hematological malignancies and post Allogenic Hematopoietic Stem Cell Transplant with favorable and safe outcome 17,18 . Similarly, its utility in cancer patients (including those who are actively receiving chemotherapy) was reported and suggests its safe administration even among neutropenic patient's subset 19,20 …”

Severe acute respiratory syndrome coronavirus 2 infection in the stem cell transplant recipient − clinical spectrum and outcome

“…Finally, and although beyond the scope of the present review, the precise role of immunomodulatory (i.e. tocilizumab [50]) or antiviral agents (i.e. remdesivir [51]) in the HSCT population should be established by means of prospective collaborative efforts, as well as the strategies to improve the immunogenicity of mRNA-based vaccines [52,53].…”