Refractory giant cell arteritis on prednisone and tocilizumab: improvement with subsequent tuberculosis reactivation

Kherani, Irfan; Chin, Carson; Kherani, Raheem B.; Kherani, Femida

doi:10.1016/j.jcjo.2018.11.005

Cited by 4 publications

(5 citation statements)

References 6 publications

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“…2,11 COVID-19 is similar to Influenza with regard to incidence of ARDS but unique with regard to cytokine storm which is being treated with immunomodulators such as IL-6 antagonist Tocilizumab. Tocilizumab has been associated with risk of severe infections particularly tuberculosis 12 and recurrent allergic bronchopulmonary aspergillosis. 13 Although clinically significant disease requiring treatment was present in five out of nine cases, the beta-D-glucan was elevated in only one case and serum galactomannan was not elevated in any of the cases.…”

Section: Re Sultsmentioning

confidence: 99%

COVID‐19‐associated pulmonary aspergillosis (CAPA) in patients admitted with severe COVID‐19 pneumonia: An observational study from Pakistan

Nasir

Farooqi

Mahmood

et al. 2020

Mycoses

166

194

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Background Invasive aspergillosis is a well‐known complication of severe influenza pneumonia with acute respiratory distress syndrome (ARDS). However, recent studies are reporting emergence of aspergillosis in severe COVID‐19 pneumonia, named as COVID‐19 associated aspergillosis (CAPA). Methods A retrospective observational study was conducted in patients with severe COVID‐19 pneumonia from February 2020‐ April 2020. Patients’ ≥18 years of age with clinical features and abnormal chest imaging with confirmed COVID‐19 by RT‐PCR for SARS‐Cov‐2 were included. CAPA was diagnosed based on clinical parameters, radiological findings and mycological data. Data were recorded on a structured proforma and descriptive analysis was performed using Stata ver 12.1. Results A total of 147 patients with confirmed COVID‐19 and 23 (15.6%) patients requiring ICU admission were identified. Aspergillus species were isolated from tracheal aspirates of nine (39.1%) patients and of these five patients (21.7%) were diagnosed with CAPA and four (17.4%) had Aspergillus colonization. The mean age of patients with CAPA was 69 years (Median age: 71, IQR: 24, Range: 51 – 85) and 3/5 patients were male. The most frequent co‐morbid was diabetes mellitus (4/5). The overall fatality rate of COVID‐19 patients with aspergillosis was 44% (4/9). The cause of death was ARDS in all 3 patients with CAPA and the median length of stay was 16 days (IQR: 10; Range 6‐35 days). Conclusion This study highlights the need for comparative studies to establish whether there is an association of aspergillosis and COVID‐19 and the need for screening for fungal infections in severe COVID‐19 patients with certain risk factors.

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Section: Re Sultsmentioning

confidence: 99%

COVID‐19‐associated pulmonary aspergillosis (CAPA) in patients admitted with severe COVID‐19 pneumonia: An observational study from Pakistan

Nasir

Farooqi

Mahmood

et al. 2020

Mycoses

166

194

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“…It is possible that the observed visual recovery may represent a delayed effect of GC treatment. However, the aforementioned reports (8–10) and our case series describing rapid improvement of GCA symptoms following tocilizumab alongside how steroids only stabilize, not acutely improve, visual acuity and prior consensus concluding steroids uncommonly improve VA support a cause–effect relationship (3). The exact mechanism of how tocilizumab leads to recovery of vision is not known.…”

Section: Discussionmentioning

confidence: 69%

“…Kherani et al described a case of GCA where the patient's contralateral eye developed an arteritic AION despite being on prednisolone with consequent VA decline from 6/15 to 6/60. With IV 8 mg/kg 4 weekly tocilizumab, BCVA had improved from 6/60 to 6/15 at a 4-month follow-up (8). Svasti-Salee et al reported a case of biopsy-proven GCA complicated by decline in VA from 6/ 9 to HM with an ischemic optic neuropathy and central retinal artery occlusion in the RE despite treatment, 3 IVMP doses and 13 days of oral prednisolone.…”

Section: Discussionmentioning

confidence: 99%

The Role of Tocilizumab in Glucocorticoid Resistant Giant Cell Arteritis: A Case Series and Literature Review

Stretton¹,

Tan²,

Hassall³

et al. 2022

Journal of Neuro-Ophthalmology

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Background:Glucocorticoid-resistant giant cell arteritis (GCA) describes a subgroup of patients whose visual acuity further declines despite immediate administration of high-dose intravenous glucocorticoids. Tocilizumab, a recombinant humanized anti-interleukin-6 receptor monoclonal antibody may be used as “rescue” therapy in these cases but requires more research.Methods:We present a literature review on tocilizumab as rescue therapy and a retrospective case series of 5 consecutive glucocorticoid (GC) resistant, temporal artery biopsy (TAB) negative patients.Results:The use of tocilizumab as rescue therapy for GC-resistant GCA is limited to 3 case reports. Two cases saw visual acuity improvement in the newly affected contralateral eye after 8 mg/kg of intravenous tocilizumab (from 6/60 to 6/15 in one case and hand motion to 6/6 in another). The third described stabilization and prevention of further best-corrected visual acuity (BCVA) decline. All 5 of our patients presented with acute monocular vision loss. BCVA ranged from 6/12 to light perception (LP). All patients were promptly commenced on 1 g intravenous methylprednisolone daily. Weekly 162 mg of subcutaneous tocilizumab was commenced once contralateral eye involvement was noted. Tocilizumab resulted in bilateral BCVA gains in 2 cases, recovery of the contralateral eye in one, and no effect in the remaining 2 cases. BCVA recovery was no light perception to 6/6 after 6 weeks of tocilizumab. Tocilizumab had no effect in cases with severe vision loss and high C-reactive protein on presentation.Conclusions:We agree with existing hypothesis that tocilizumab likely prevents a “pending” central retinal artery occlusion by maintaining retinal vasculature perfusion. Our case series suggests that there is a role for tocilizumab as “rescue” therapy for GC-resistant GCA, where vision loss would otherwise be imminent.

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“…One such case report points out hypofibrinogenemia as a possible side effect which can increase bleeding risk; also, it reports neutropenia and thrombocytopenia as, albeit rare, side effects (6). Another case describes fatal tuberculosis reactivation in a GCA patient treated with TCZ, despite an initial negative screening result (7). TCZ was also shown to induce cutaneous sarcoidosis in a GCA patient, although this was also previously found in RA patients on TCZ (8).…”

Section: Original Scientific Papermentioning

confidence: 79%

“…(6). U drugom se prikazu opisuje reaktivacija tuberkuloze sa smrtnim posljedicama u pacijenta koji je bolovao od GCA i liječio se primjenom TCZ-a, premda je prvotni rezultat njegova testa za probir bio negativan (7). Također, dokazana je uloga TCZ-a u induciranju kožnog oblika sarkoidoze u pacijenta koji boluje od GCA, iako je to prethodno prikazano u oboljelih od reumatoidnog artritisa što su primali TCZ (8).…”

Section: Original Scientific Paperunclassified

Treatment of Giant Cell Arteritis Using Tocilizumab*

Šimac

Novak

2021

Reumatizam

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Giant cell arteritis (GCA) or temporal arteritis (TA) is a large-vessel vasculitis of the elderly which, if untreated, can lead to blindness. Glucocorticoids (GCs) remain the main treatment, but high-dose and long-term use can lead to serious side effects. Tocilizumab (TCZ) is increasingly used as an alternative steroid-sparing treatment option with promising results. This case series presents three GCA patients with a refractory form and/or at high risk for side effects treated with TCZ due to diagnoses of glaucoma and osteoporosis. Two of the patients responded to the treatment with good results. All three patients are elderly females who initially presented with classic symptoms of headache and/ or vision loss. The first patient also presented with fever, and the second with jaw claudication. Both of them were treated with pulses of GCs, but since the first also had osteoporosis with vertebral fractures, and the second had glaucoma and remained on high doses, TCZ was introduced. Both patients have since been stable. After approximately five years, the third patient developed TA with rheumatic polymyalgia, which was successfully treated with GCs. Later on TCZ was introduced as GCs could not be discontinued in consideration of the presence of osteoporosis and glaucoma. TCZ was discontinued after the patient developed neutropenia. Our case series presents two successful cases of treating GCA patients with TCZ, solidifying the recommendations for TCZ as a viable option for refractory disease and patients at high risk for side effects.

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Refractory giant cell arteritis on prednisone and tocilizumab: improvement with subsequent tuberculosis reactivation

Cited by 4 publications

References 6 publications

COVID‐19‐associated pulmonary aspergillosis (CAPA) in patients admitted with severe COVID‐19 pneumonia: An observational study from Pakistan

COVID‐19‐associated pulmonary aspergillosis (CAPA) in patients admitted with severe COVID‐19 pneumonia: An observational study from Pakistan

The Role of Tocilizumab in Glucocorticoid Resistant Giant Cell Arteritis: A Case Series and Literature Review

Treatment of Giant Cell Arteritis Using Tocilizumab*

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