Report Describes Patient With MM, COVID-19 Treated Successfully With Tocilizumab

Older patients are already at a higher risk of severe disease if they contract coronavirus disease 2019 (COVID-19), but a new study explores what happened when a 60-year-old became ill with the disease while suffering from multiple myeloma (MM).

The case occurred in China, and was written about in the current issue of Blood Advances. The patient, who lives in Wuhan, was first diagnosed with symptomatic MM back in 2015. Back then, a bone marrow aspirate showed 17.1% clonal plasma cells, and radiography showed multiple osteolytic bone lesions in frontal and temporal bone.

“His kidney biopsy confirmed amyloidosis; laboratory testing also showed proteinuria,” reports corresponding author Chengchang Zheng, PhD, of the University of Science and Technology of China. “The patient received 2 cycles of induction chemotherapy consisting of bortezomib, thalidomide, and dexamethasone, and his symptoms completely disappeared.”

The patient subsequently refused bortezomib-based treatment, Zheng reports, and was therefore given thalidomide as a maintenance therapy.

Five years later, the patient visited his local hospital in Wuhan on February 1, 2020, after experiencing chest tightness without a fever or cough. Physicians ordered a CT scan, which showed multiple ground-glass opacities and pneumatocele in both subpleural spaces. Doctors prescribed intravenous moxifloxacin and ordered nasopharyngeal tests for SARS-CoV-2, the virus that causes COVID-19. When the test came back positive, the patient was given 200 mg of the antiviral umifenovir, taken orally 3 times each day.

Two weeks later, on February 16, the patient was diagnosed with severe disease after experiencing shortness of breath and decreased arterial saturation of around 93% at rest. He was admitted to a cancer center at his hospital.

Zheng wrote that the immune incompetence of patients with malignancies not only puts them at a higher risk of contracting COVID-19, but also increases the potential for treatment difficulties. He also noted that the patient’s symptoms in this case differed somewhat from the most common symptoms of COVID-19—fever and cough–indicating that symptoms may be atypical in patients with comorbidities.

In treating the patient, Zheng and colleagues looked to emerging research about the disease.

“As one of the important cytokines that can lead to an acute severe systemic inflammatory reaction known as a cytokine storm, IL-6 can also active the coagulation pathway and inhibit myocardial function, much like the clinical characteristics of severe COVID-19,” Zheng said.

He pointed to a previous study that suggested severe lung pathology might be associated with excessive immune responses by pathogenic T cells and inflammatory monocytes, and therefore “a monoclonal antibody targeting the IL-6 receptor might be effective in the treatment of novel coronavirus pneumonia.”

Based on that and other information, the patient was given the IL-6 receptor inhibitor tocilizumab and gradually recovered.

“IL-6 signaling plays a crucial role in the pathogenesis of MM, and small molecule inhibitors targeting IL-6 signaling are highly effective at preventing MM cell growth,” Zheng said. “We speculate that tocilizumab might also have potential benefit for MM as an immunotherapy in the future.”

As with all new therapies aimed at COVID-19, Zheng concluded by noting that clinical trials would be needed to confirm whether the experience of this particular patient could be reliably replicated in other patients with MM and COVID-19.

Reference

Zhang X, Song K, Tong F, et al. First case of COVID-19 in a patient with multiple myeloma successfully treated with tocilizumab. Blood Adv. 2020;4(7):1307—1310. doi:10.1182/bloodadvances.2020001907.