LAUSR

Patient 1. A 49-year-old woman on hemodialysis (HD) because of IgA nephropathy was admitted with a dry cough and fever that persisted for 48 h (38.5 °C), without dyspnea; she was found positive to SARS-CoV-2 (RT-PCR assay). She had been on HD since 1996, received a kidney transplant in 2007, which failed in 2018. On examination O2 saturation was 92% in room air, arterial O2 tension (PaO2) was 68 mmHg. Chest X-Ray showed interstitial thickening in the right lower perihilar area and a small parenchymal consolidation in the left perihilar area. She was treated with hydroxychloroquine (200 mg two times/day for two days, then 200 mg/post-HD for ten days), ceftriaxone (1 g/ day), N-acetyl cysteine (300 mg two times/day), prednisone (5 mg/day), enoxaparin (8000–10,000 UI/day) and oxygen therapy at an initial dose of 6 lit/min. However, we found a progressive alteration of biomarkers, including low lymphocyte and monocyte counts, increased C-reactive protein (CRP), high LDH levels [1] (Fig. 1a) and increased requirement of oxygen therapy (rising up to 8–10 lit/min); chest high-resolution computed tomography (HRCT) confirmed atypical pneumonia involving over 60% of the lung parenchyma (Fig. 1b, c). Six days later she showed no improvement and a significant increase in IL-6 levels (41.07 pg/ml, normal range 0.5–6.4). Tocilizumab rescue therapy was started (8 mg/kg). One day later cough and fever attenuated and we observed a progressive normalization of lymphocyte and monocyte counts as well as of CRP and LDH levels (Fig. 1a), associated with complete disappearance of lung lesions (Fig. 1d–f). Interestingly, the oropharyngeal swab test became negative only after 37 days. Patient 2. A 36-year-old woman on HD regimen for six years was admitted to our unit with fever (37.2 °C), and a dry cough that started 3 days before admission. Initial evaluation showed O2 saturation 88% in room air, PaO2 of 52 mmHg and positivity to SARS-CoV-2 swab. After observing a significant decrease in lymphocyte and monocyte counts, and altered CRP and LDH levels (Fig. 2a–d), we administered a single dose of Tocilizumab (8 mg/kg, 360 mg) on day 3 of hospital admission (6 days from symptom onset). Fever immediately remitted and lymphocyte and monocyte counts, CRP and LDH progressively normalized (Fig. 2a–d); O2 therapy was discontinued 10 days after Tocilizumab with improvement of the atypical pneumonia (Fig. 2e–f). Patient 3. A 70-year-old male on HD treatment for 12 years with undiagnosed CKD, diabetes mellitus, and dilated cardiomyopathy was admitted with fever and was found positive to SARS-CoV-2. He was treated with hydroxychloroquine (200 mg two times/day for 2 days, then 200 mg/post-HD for 10 days), ceftriaxone (1 g/day), prednisone (5 mg/day), enoxaparin (8000–10,000 UI/day) and oxygen at 8 lit/min. After 4 days, due to clinical worsening he was treated with Tocilizumab (8 mg/kg; 640 mg). A rapid decrease in body temperature was observed and complete resolution of pneumonia was documented. Giuseppe Castellano and Barbara Infante equally contributed to the present study.