Tocilizumab-induced Cytomegalovirus Colitis in a Patient with COVID-19

Abstract

Cytomegalovirus (CMV) infection exists in 50-80% of the world's population in clinically undetected form due to their immunocompetent status. Here we report a case of a 42-year-old COVID-19 patient with no past medical history, who received tocilizumab, which led to a massive lower gastrointestinal bleeding not responded to medical management.

First case of concomitant cytomegalovirus (CMV) viremia in non‐immunocompromised COVID‐19 patient and ICU management strategy in Qatar with literature review

“…Our patient was not immunocompromised; however, one possibility that could have led to concomitant CMV infection would be dysregulated immunity due to underlying severe COVID‐19 infection creating an immunocompromised state 3,6 . Furthermore, immunosuppressive medications such as steroids and tocilizumab can also suppress immunity along with COVID‐19‐induced dysregulated immunity making a patient prone to life‐threatening infections 3,7,9–11 . Currently, there are no international standard management guidelines for such a challenging scenario of CMV infection in COVID‐19 patients.…”

“…3,6 Furthermore, immunosuppressive medications such as steroids and tocilizumab can also suppress immunity along with COVID-19-induced dysregulated immunity making a patient prone to lifethreatening infections. 3,7,[9][10][11] Currently, there are no international standard management guidelines for such a challenging scenario of CMV infection in COVID-19 patients. However, in the literature, it is reported that early diagnosis of CMV viremia in highly suspected COVID-19 patients and management with anti-viral therapy, that is, ganciclovir, valganciclovir, and in some instances with Foscarnet, can be of proven benefit.…”

Characteristics and clinical outcomes of COVID‐19 patients with pulmonary disorders: A single‐center, retrospective observational study

“…Drug‐induced immunosuppression also plays a role in making patients susceptible to secondary infections. Pettit et al reported significantly increased late‐onset infections among those receiving tocilizumab, 28 such as cytomegalovirus colitis 29 . Kimmig et al 30 also reported a significantly higher rate of secondary infections and mortality in their cohort of patients who received tocilizumab.…”

Cytomegalovirus gastritis in a patient with severe acute respiratory syndrome coronavirus 2 infection: A case report and literature review

“…Biopsies demonstrated near-complete loss of epithelium and CMV-infected cells by IHC. Positive blood CMV PCR CMV hemorrhagic enterocolitis Remdesivir, convalescent plasma, corticosteroids, tocilizumab, ustekinumab, ganciclovir, foscarnet Recovered Silvano et al [ 24 ] 55-year-old female K/C of kidney transplant Cough and fever – – CMV colitis HCQ Recovered Khatib et al [ 25 ] 42-year-old male Fever, dyspnea, cough and generalized myalgia Melena and hemoglobin decrease further complicated by fresh rectal bleeding; mural thickening with intramural axial hemorrhage involving the splenic flexure and descending colon in CT angiogram Histopathological study of the resected colon reported CMV colitis. Colonic perforation and serology confirmed CMV infection.…”