V.NALLAKARUPPAN1, S.NG1, S.T.OOI1
Khoo Teck Puat Hospital1
The pathophysiology of severe COVID-19 pneumonia has been associated with hyperinflammatory response. Corticosteroids and tocilizumab have shown to reduce mortality but their benefits in clinical use is not fully understood with varied clinical outcomes.
We present three Covid-19 cases in various stages of illness.
In Case 1, a 66 year-old man presented with 14 days of fever, cough and breathlessness was diagnosed with bilateral COVID-19 pneumonia and needed intubation. He was administered tocilizumab alone and was successfully extubated 2 days after.
In Case 2, a 59 year-old man presented early with 1 day of fever, cough and a normal Chest X-ray. However, he progressed to develop pneumonia and respiratory failure despite good inflammatory control with tocilizumab given on day 6 of illness. He had not received optimal doses of hydroxychloroquine in view of the SVT episodes on admission.
In Case 3, a 34 year-old man presented on day 4 of illness with fever, cough and left lower zone pneumonia, progressed to bilateral pneumonia requiring oxygen supplementation. There was marked clinical improvement after hydroxychloroquine and prednisolone administered on day 9 of illness.
It was observed that Tocilizumab alone was effective in the patient presenting in the later stage of illness where the disease is predominated by a hyperinflammatory state. However, the patients in the earlier phase of illness needed a combination of an antiviral and anti-inflammatory agent. This is consistent with the pathophysiology of COVID-19. Treatment is best when tailored according to the phase of illness.