key: cord-0792169-0trg6dk3
authors: Wu, Hao-Yu; Pan, Chien-Ting; Cheng, Chiao-Feng; Lin, Chi-Ying; Chang, Sheng-Nan; Chen, Yi-Chung; Wang, Chih-Yuan; Chen, Yen-Fu; Chen, Chung-Yu; Matthew Ma, Huei-Ming; Hwang, Juey-Jen
title: Combined Intravenous Immunoglobulin and Baricitinib Treatment for Severe COVID-19 with Rhabdomyolysis: A Case Report
date: 2021-03-24
journal: J Formos Med Assoc
DOI: 10.1016/j.jfma.2021.03.014
sha: 38b1e3927236c97b9483247a51ec00f44d8f839b
doc_id: 792169
cord_uid: 0trg6dk3

Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) has spread rapidly around the world. The severity of COVID-19 ranges from asymptomatic carriers to severe acute respiratory distress syndrome (ARDS). Accumulating evidence has shown that COVID-19 may be associated with multiple organ complications including cardiac injury, viral myositis and neurological deficits. Numerous laboratory biomarkers including lymphocytes, platelets, lactate dehydrogenase and creatine kinase (CK) have been associated with the prognostic outcomes of patients with COVID-19. However, dynamic correlations between levels of biomarkers and clinical course have not been studied. Herein, we report a 74-year-old female patient with severe COVID-19 which progressed to ARDS requiring intubation and mechanical ventilation. The laboratory findings showed lymphopenia, hypogammaglobulinemia, and elevated inflammatory biomarkers and CK. She received intensive therapy with hydroxychloroquine, lopinavir/ritonavir, and azithromycin with limited effects. Immunomodulatory treatments with high dose intravenous immunoglobulin and baricitinib were prescribed with satisfactory biochemical, radiographic and clinical recovery. We found an interesting correlation between serum CK elevation and inflammatory biomarkers, which reflected clinical improvement. This case demonstrates that inflammatory biomarkers, cytokines, and CK level correlated with disease severity and treatment response, and combined use of intravenous immunoglobulin and baricitinib is a potential treatment in patients with severe COVID-19.

The novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), In mid-March 2020, a 74-year-old female patient was admitted to a hospital in 4 southern Taiwan due to a close contact history with her daughter, a confirmed case of 5 COVID-19. They had traveled for 10 days to eastern Europe in early-March 2020 6 with a tour group. The patient had type 2 diabetes mellitus and hypertension. She 7 denied fever, productive cough, myalgia, dyspnea, or diarrhea during her travel. Her 8 daughter, with whom she stayed during the whole trip, had productive cough and 9 fever for a few days before arriving in Taiwan and was admitted to the hospital for 10 definite COVID-19.

The patient developed a fever on admission, and her oxygen saturation was 97% hypotension with normal lactate level was noted, so she was given low dose 2 norepinephrine and gentle hydration. In addition, hypogammaglobulinemia (IgG 509 3 mg/dL, reference range: 700~1600 mg/dL) was found with severe lymphocytopenia.

Due to an increased level of IL-6 (363.14 pg/mL, reference range: not detectable), Virus-associated rhabdomyolysis, which has been described and is most 18 commonly seen in influenza A and B viruses infection, 5-7 may have been implicated in the first peak of CK level in our patient because of rapidly deteriorating clinical 1 symptoms and probable cytokine storm syndrome. A previous study reported that the 2 initial peak level of CK was a predictor of mortality in COVID-19. 8 The possible 3 pathophysiology of viral-related rhabdomyolysis may be direct muscle invasion by 4 the virus, inflammation reaction resulting in collateral muscle damage, and viral 5 toxins causing direct muscle injury. 9 A decline in serum CK level has been 6 significantly correlated with the treatment response to COVID-19 infection. 10 It is 7 possible that cisatracurium would worsen rhabdomyolysis, but we considered 8 cisatracurium use is not the major contributing factor of CK elevation since the 9 dosage of cisatracurium used was within even below the suggested mean maintenance There is currently limited effective treatment for COVID-19. The short-term use of dexamethasone has been shown to lower the 28-day mortality rate in COVID-19 1 patients with oxygenation support demand. 12 However, the therapeutic benefits of 2 other medications targeting COVID-19 including lopinavir/ritonavir, azithromycin 3 and hydroxychloroquine are still uncertain. 13 Tocilizumab, a humanized monoclonal 4 antibody against the IL-6 receptor, is a potential candidate for it anti-inflammatory high-sensitive C-reactive protein (hsCRP), and procalcitonin with major clinical

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