July 2, 2020

Infliximab treatment for severe ulcerative colitis and subsequent COVID-19 pneumonia

In a case report published in Gut, Cristina Bezzio, Gastroenterology Unit, ASST Rhodense, Garbagnate Milanese, Italy, and colleagues detailed the first case of an adult patient with severe ulcerative colitis and coronavirus disease 2019 (COVID-19) pneumonia who they said was successfully treated for both conditions with infliximab.

A 36-year-old man was admitted to hospital for a severe recurrence of ulcerative colitis. At admission, he had been taking mesalazine both orally and topically, and he reported up to 12 bowel movements with blood. 

Laboratory tests showed mild normocytic anaemia (haemoglobin, 123 g/L), neutrophilic leucocytosis (neutrophils, 9420/μL), increased C-reactive protein (CRP) (17.1 mg/dL; normal values <0.5 mg/dL) and hypoalbuminaemia (3.2 g/dL). Additionally, colonoscopy showed widely ulcerated mucosa, and a histological examination confirmed severely active ulcerative colitis. Meanwhile, chest and abdominal radiographs were normal. 

The patient was started on intravenous methylprednisolone (60 mg/day), fluid replacement and antithrombotic prophylaxis with low-molecular-weight heparin. Stool culture, Clostridium difficile toxin assay and one nasopharyngeal swab test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were negative. In addition, screening for infections, as recommended prior to prescribing biological therapies, was negative.

After 5 days of intravenous methylprednisolone, the authors noted that the patient's general well-being and clinical conditions had "slightly improved," and CRP levels had dropped to 0.95 mg/dL. A proctosigmoidoscopy excluded cytomegalovirus infection. 

"At this point, rescue therapy would have been appropriate, but the patient developed fever, dyspnoea and cough," the authors wrote, adding that laboratory tests showed the return of high CRP levels (3.98 mg/dL). Further, CT showed bilateral patchy ground-glass opacities, indicating severe interstitial pneumonia. A repeat nasopharyngeal swab tested positive for SARS-CoV-2, and steroid therapy was tapered and moved to oral administration. The patient’s interleukin 6 (IL-6) serum levels were found to be abnormally high at 37.4 pg/mL (normal values: 0–7 pg/mL).

Surgery was considered to treat the ulcerative colitis, but the authors instead opted to administer infliximab at a dose of 5 mg/kg as "surgery seemed to be contraindicated in a patient with COVID-19, which could complicate the postoperative course and be potentially fatal." They also pointed to a recent study they conducted that "found no association between the use of biological therapies and poor outcomes of IBD (inflammatory bowel disease) patients and COVID-19."

The authors said that after 7 days on infliximab, the patient's intestinal symptoms and general well-being had "markedly improved," with CT showing reduced extent and density of the ground-glass opacities, while CRP and IL-6 levels dropped to 0.12 mg/dL and 15.9 pg/mL, respectively. In addition, two consecutive nasopharyngeal swab tests for SARS-CoV-2 were negative. The patient was discharged in good clinical condition, with two bowel movements without blood in the stools. 

"The scheduled second infusion of infliximab has been performed and in few days he will complete induction regimen," the authors said.

"The improvement of pulmonary symptoms suggests that anti-tumour necrosis factor alpha (TNF-α) agents may be an effective therapy for COVID-19. Furthermore, the positive outcome is a reassuring message for clinicians considering the initiation or continuation of anti-TNF alpha therapy in IBD patients with active disease and COVID-19," they concluded.

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