ImmunosuppressionandCOVID-19:TheHamburgexperience

PDDr.med.JulianSchulzezurWiesch1.MedicalDepartmentUniversityMedical

I. MedizinischeKlinikundPoliklinik

OurheartsgoouttoalloftheCOVID-19patients,theirfamilies andtheirproviders!

Let´stacklethisinaunitedway!

COVID-19is amilddisease inthe majority of patients

preprint

Superspreader?

Stand03.06.2020

CNNApril252020

CRS- Pathomechanism

XShimabukuro-Vornhagen etal,Cytokine release syndrome

ChiZhangetal.,Thecytokine release syndrome (CRS)of severe COVID-19and Interleukin-6receptor (IL-6R)antagonist Tocilizumab may be the key to reduce themortality

Stages:1. Replicative Phase

2. Phaseof the (adaptive)

immuneresponse

„Thisprogression may

explain the clinicalphenomenon wherein

patients are relatively OKfor several days,butthen

suddenly deteriorate when

they enter the adaptiveimmunity stage“(e.g.Young

etal.3/3/2020)

Casestudy3:Off-label therapyofimmunocompetentpatientswithTocilicumab(Don´tdothisathome– orjustwithincontrolledstudies)

Patient2

*

*

Off-labeluseofTocilizumab8mg/Kg twopatientswithprotracteddiseasecourse-patientsweredischarged7dayslaterinexcellenthealth

Resultsofcontrolledstudiesareneeded-(Futuredirection? Immunomodulation +SARS-CoV2antiviral)

Patient1

CourtesyH.Wege

231influenzapatients36%immunesuppressed15,3%nosokomial infectionsmortality9%(71%immunesuppressed)

Bundesgesundheitsblatt 2019

PreliminaryresultsUKECOVID-19cohort(AdmissionsMarch1st–untilMay1st)

Stillinhospital:7PtsICU,10IDward

MvM,TBUKE–unpublisheddatapleasedon´tdistribute

149COVID-19patients24,2%immunesuppressed16,1%nosokomial infectionsmortality14%(47,8% immunesuppressed)

Immunosuppression- onlyoneofmanyriskfactors….

HypertensionAgeDiabetesSexBMIHematologicdiseaseOngoing ChemotherapyCOPD/LungdiseaseCoronaryheartdiseaseHeartfailureKidneydiseaseImmunosuppressionGeneticfactors?VirusstrainSizeViralinoculumCirrhosisEtc..

RISKforcomplicationsIncreasedmortality

Generallymilddiseasecourse

Riskfactorsseemtoaddup

Source:SzW-hisownobservationsandhypothesis

Flatteningthecurve…butinsomecasesprolongingthediseasecourse

?Chronicity ?Versusresolution

HSCTpatients?DetrimentalcourseOrganfailure

CRS?

Source:SzW- hisownobservationsandhypothesis– drawingSzW+MSW

Weneedtostudymoreandcombiningdifferentavenues!

CourtesyMSW!

Takehomemessages• First rule: we have to calm our patients (and ourselves) – there is a lot of fear!– Stay on their stable immunosuppressant medications, - Stay in good health (light training, sleep, food) - Stick to the general COVID-19 distance/hygene rules- There are COVID-19 guidelines issued by the respective medical soceity- Update vaccination status- There is no preemptive –COVID-19 medication-- Do not schedule unnecessary appointments but do also not cancel nessessary ones.

• The clinical COVID-19 course of immunosuppressed course can vary greatly:- Mostly benign course (some patients might have even fewer symptoms)- Some might have higher SARS-Cov2 PCR CT values in swabs and even viremia!- Sometimes longer PCR+- chronicity, relapse ? Eg swabs+ sputum+- In some patients no/weak/delayed Ab response develops- HSCT COVID-19 patients seem to have dismal outcome- Immunosupressants as needed for primary disease- Treat COVID-19 with same with supportive treatment as immunocompetent patient- Interdisciplinary thinking – boards – especially before planed off-label treatment

• Let´s be vigilant and avoid In-hospital outbreak situations- Cave: Tx , cancer and HSCT wards !- Test, test, test

• We need to learn much more about COVID-19 in the immunosuppressed patient.

• History of