key: cord-0753394-b7yiaiyb
authors: Sernicola, A; Carnicelli, G; Di Fraia, M; Chello, C; Furlan, C; Muharremi, R; Paolino, G; Grieco, T
title: “Toxic erythema” and eosinophilia associated to tocilizumab therapy in a COVID‐19 patient
date: 2020-05-09
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16620
sha: 07279c0e1b33485a26b10159f3572c3663cffdfb
doc_id: 753394
cord_uid: b7yiaiyb

Since the new fatal pneumonia was identified in December 2019 in Wuhan, China, the WHO declared the infection a health emergency of international concern. The novel ss‐RNA ß‐coronavirus (SARS‐CoV‐2) spreads through airborne and direct contagion; virulence is high in the elderly and in patients with diabetes, chronic pulmonary, cardiovascular and neoplastic diseases. SARS‐CoV‐2 ssRNA is recognized by intracellular Pattern Recognition Receptors (PRRs), which trigger NF‐kB – the master regulator of inflammation – and Interferon Regulatory Factors (IRFs)(1).

The novel ss-RNA ß-coronavirus (SARS-CoV-2) spreads through airborne and direct contagion; virulence is high in the elderly and in patients with diabetes, chronic pulmonary, cardiovascular and neoplastic diseases. SARS-CoV-2 ssRNA is recognized by intracellular Pattern Recognition Receptors (PRRs), which trigger NF-kBthe master regulator of inflammationand Interferon Regulatory Factors (IRFs) 1 . These regulators induce type I interferon (IFN-α/β) production, along with a series of acute phase cytokines, mainly TNFα/ß, IL-1ß and IL-6, powerful mediators of Th1-like inflammatory response 2,3 . IL-6 acts both locally, to activate lymphocytes, and systemically, to induce fever and production of acute phase proteins. IL-6 has been recognized as one of the most accurate biomarkers predictive of death in clinical sepsis 4 . The main pathogenic mechanism related to COVID-19 is the cytokine storm, characterized by massive release of pro-inflammatory cytokines and chemokines that characterize highly aggressive fatal forms 3 . Characteristic findings are leukopenia and lymphocytopenia. Chest CT shows typical diagnostic patterns of ground-glass opacities and bilateral patchy shadowing 3 . Severe forms are also characterized by neutrophilia, increase in D-dimer and IL-6 serum levels; the latter marker is a main culprit of the cytokine storm and is considered a strong negative prognostic factor. In COVID-19related cytokine storm, tocilizumaba humanized monoclonal antibody targeting IL-6 cytokine receptorhas been proposed as effective biological treatment and is currently being evaluated in large-scale RCTs (NCT04346355).

This article is protected by copyright. All rights reserved In the SARS-CoV2-era, the appropriate strategy for the treatment of the cytokine storm is a topic of great interest and awareness of unusual side effects, as that in our report, could help physicians to better manage these critical patients.

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Molecular immune pathogenesis and diagnosis of COVID-19

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Hypersensitivity reactions to tocilizumab: role of skin tests in diagnosis

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Tocilizumab-induced drug reaction with eosinophilia and systemic symptoms syndrome in adult-onset still disease

Tocilizumab-induced drug reaction with eosinophilia and systemic symptoms (DRESS) in a patient with rheumatoid arthritis

The patient in this manuscript has given written informed consent to the publication of their case details.