SARS-CoV-2 (COVID-19) pneumonia patient treated with two doses of infliximab within 2 weeks for acute severe ulcerative colitis

Abstract

Rationale: The ongoing coronavirus pandemic has caused severe acute respiratory syndrome, posing a significant challenge for patients receiving immunotherapy for immune-mediated inflammatory diseases. As of January 2022, immunosuppressants such as tumor necrosis factor inhibitors (anti-TNFα) and azathioprine are inadvisable for an infectious disease caused by the SARS-CoV-2 virus (COVID-19). We continued infliximab as a second induction dose nine days after the onset of COVID-19 symptoms in a patient with acute severe ulcerative colitis. Patient concerns: We report the case of a 34-year-old male with 6 to 8 times bloody diarrhea, fever, and cramping abdominal pain. Ulcerative colitis was diagnosed 6 months earlier and treated with mesalamine 80 mg/kg/day and azathioprine 2.5 mg/kg/day. The patient had never undergone surgery before. Sigmoidoscopy revealed multiple ulcerations and spontaneous bleeding, and the colon samples tested negative for cytomegalovirus and Clostridium difficile. However, intravenous corticosteroids did not induce remission. A nasopharyngeal swab tested positive for SARS-CoV-2. Diagnosis: Acute severe ulcerative colitis and SARS-CoV-2 (COVID-19) pneumonia. Interventions: The second loading dose of infliximab was administered nine days after the diagnosis of COVID-19. Outcome: The patient completed infliximab induction at a dose of 5 mg/kg at weeks 0, 2, and 6, with no complications. Lessons: It is unclear whether anti-TNF-α treatment improves or deteriorates COVID-19 patient outcomes, and this case demonstrates that infliximab can be used safely. Current guidelines make a weak recommendation to avoid using anti-TNFα agents in the presence of acute COVID-19 infection. There is an urgent need for research on biologics therapy.

An older patient with active ulcerative colitis and coronavirus disease 2019 (COVID-19) pneumonia successfully treated with the combination of anti-TNFα therapy and azathioprine

“…Taken together, these data strongly support the clinical course that anti-TNFα agents do not worsen the COVID-19 infection. Alhalabi et al reported a case of a UC patient with COVID-19 pneumonia who was safely treated with an anti-TNFα agent [ 25 ]. However, data remain limited on the efficacy and the safety of anti-TNFα treatment in patients with COVID-19, based on large-scale clinical trials.…”

Managing IBD in the COVID-19 era

“…73 Additionally, clinicians observed higher levels of pro-inflammatory cytokines, namely TNF-a and IL-6, are present in concomitant IBD and COVID-19 than in either entity alone. 73 Follow-up studies from both Bezzio et al 74 and Alhalabi et al 75 have demonstrated the safety and efficacy of infliximab induction in patients with ASUC and acute COVID-19 pneumonia. In the former study, researchers appreciated a resolution of pulmonary symptoms in addition to IBD remission after treatment with anti-TNF therapy.…”

Cytokine Profile of Invasive Pulmonary Aspergillosis in Severe COVID-19 and Possible Therapeutic Targets

“…As a matter of fact, anti-TNF agents have an important anti-inflammatory effect and the ability to reduce the expression of some cytokines associated with poor outcomes in COVID-19 pneumonia [ 23 ]. As far as we know, there are no RCTs on the use of anti-TNF in severe COVID-19, and our knowledge derives from indirect observations of patients who are on anti-TNF drugs for underlying comorbidities and who contract SARS-CoV-2 infection; observational studies suggest that those patients tend to have a better outcome [ 59 , 60 ]. Therapy with anti-TNF antibody infliximab, however, is considered a major risk factor for IPA infection, with an even higher incidence described when the patient is in concomitant chronic steroid treatment [ 61 ].…”