Die Behandlung eines Patienten mit ausgeprägtem Zytokinsturm bei schwerer COVID-19-Pneumonie unter Einsatz von Hämoadsorption in Kombination mit der Gabe von Tocilizumab

Zusammenfassung

Die intensivmedizinische Behandlung von Patienten mit schwerer COVID-19-Pneumonie stellt, trotz zunehmender Erfahrungen aufgrund zunehmender Patientenzahlen, im Einzelfall weiterhin eine spezielle Herausforderung dar, welche auch einen individuellen Therapieversuch legitimiert. Eine besondere Situation stellt das sog. Hyperinflammationssyndrom dar, in dessen Rahmen es zu einem Zytokinsturm mit z. T. massivem Anstieg inflammatorischer Marker wie z. B. Interleukin-6 kommt. Die vorliegende Kasuistik beschreibt den Therapieansatz bei einem 58-jährigen, männlichen Patienten mit schwerer COVID-19-Pneumonie durch den Einsatz des IL-6-spezifischen Antikörpers Tocilizumab in Kombination mit dem Hämoadsorptionsverfahren CytoSorb. In diesem Fall war es am 6. Beatmungstag zu einer massiven klinischen Verschlechterung mit Horovitz-Indices von bis zu 127 mmHg gekommen. Nach parallelem Einsatz der genannten Therapieansätze kam es zu einer raschen klinischen Stabilisierung des Patienten mit deutlich ansteigenden Horovitz-Indices und der Möglichkeit der Deeskalation des Beatmungsregimes, welche letztlich eine erfolgreiche Extubation nach bereits 13 Beatmungstagen ermöglichte. Darüber hinaus war die kombinierte Behandlung mit einer deutlichen hämodynamischen Stabilisierung bei konsekutiver Reduktion der Vasopressor-Dosierungen assoziiert, während die Hyperinflammation gut kontrolliert werden konnte. Die Einbindung des Hämoadsorbers in das laufende Therapieregime stellte sich dabei als sicher und einfach dar. Zusammenfassend erschien die Kombination der CytoSorb-Therapie mit einer IL-6-Rezeptor-Blockade durch Tocilizumab in diesem Fall als effektive Maßnahme zur Modulation einer überschießenden Immunantwort bei COVID-19-Pneumonie mit begleitender klinischer Verbesserung der respiratorischen wie hämodynamischen Funktion und könnte somit als potenzielle therapeutische Option bei diesem Krankheitsbild eingesetzt werden.

Abstract

Despite growing experience due to increasing patient numbers, the intensive care treatment of patients with severe COVID-19 pneumonia continues to be a particular challenge in individual cases, which may also therefore legitimize individualized therapeutic attempts. In this context, the so-called hyperinflammation syndrome characterized by a cytokine storm accompanied by a massive increase in inflammatory markers such as interleukin(IL)-6, represents such a situation. This case report describes the therapeutic approach of using the IL-6-specific antibody tocilizumab in combination with hemoadsorption therapy (CytoSorb) in a 58-year-old male patient with severe COVID-19 pneumonia. The patient suffered a massive clinical deterioration with concomitant Horovitz index of 127 mmHg that occurred on the 6^th day of ventilation. After combined application of the above-mentioned therapeutic approaches, the patient stabilized rapidly paralleled by a significant increase in the Horovitz index, and the possibility of de-escalating the ventilation regimen, which ultimately enabled successful extubation after only 13 days of ventilation. Moreover, the combined treatment was associated with significant hemodynamic stabilization and a consecutive reduction in vasopressor doses, while hyperinflammation could be kept well under control. The incorporation of the hemoadsorber into the therapeutic regimen proved to be safe and straightforward. In conclusion, the combination of CytoSorb therapy and IL-6 blockade by tocilizumab appeared, at least in this case, to be an effective measure to modulate an overshooting immune response in COVID-19 pneumonia with a concomitant clinical improvement in both respiratory and hemodynamic function, and thus could be used as a potential therapeutic option in this clinical picture.

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