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Etoposide as Salvage Therapy for Cytokine 61
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Storm Due to COVID-19 63
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Q10 Maulin Patel, MD; Eduardo Dominguez, MD; Daniel Sacher, DO; Parag Desai, MD; Ashwin Chandar, MD;
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Q1 Michael Bromberg, MD; Roberto Caricchio, MD; and Gerard J. Criner, MD; the Temple University COVID-19 Research
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13 Group* 68
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16 Coronavirus disease 2019 (COVID-19) has resulted in significant morbidity and mortality 71
17 because of a lack of effective therapies. Therapeutic strategies under investigation target the 72
18 overactive cytokine response with anti-cytokine or immunomodulators therapies. We present a 73
19 unique case of severe cytokine storm resistant to multiple anti-cytokine therapies, but even- 74
20 tually responsive to etoposide. Thus, etoposide may have a role as salvage therapy in treatment 75
21 of cytokine storm in COVID-19. To our knowledge, this is the first reported case of use of 76
22 etoposide in COVID-19. CHEST 2020; -(-):--- 77
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24 Q4 KEY WORDS: COVID-19; etoposide 79
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At the time of this writing, more than 7 million people nucleocapsid proteins are combined to form the virus, 82
28 worldwide have suffered significant morbidity and which is then released from the cell. 83
29 mortality due to infection with severe acute respiratory 84
The second phase of COVID-19 presents as a
30 syndrome coronavirus-2 (SARS-CoV-2).1 Case fatality 85
heightened immune response. Similar to Middle East
31 has been noted between 2% and 3% worldwide. The 86
respiratory syndrome and SARS, SARS-CoV-2 results in
32 current literature suggests the severity of COVID-19 87
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an enhanced innate immune response with elevated IL- 88
infection is due to high levels of inflammation related to 1B, interferon-g, IP10, MCP1, MIP1A, and tumor Q5
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cytokine storm syndrome, which develops through necrosis factor alpha, and suppression of the adaptive 90
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activation of the innate immune system.2,3 Viral entry immune response as indicated by a reduced lymphocyte 91
37 into the cell occurs in two steps, similar to Middle East count.5,6 Secondary hemophagocytic 92
38 respiratory syndrome coronavirus. First, the SARS-COV lymphohistiocytosis (HLH) has a similar life-threatening 93
39 envelope spike glycoprotein binds to the cellular cytokine profile and results in a fulminant 94
40 receptor angiotensin-converting enzyme 2.4 The SARS- hyperinflammatory syndrome characterized by 95
41 COV envelope spike glycoprotein then enters the cell, its cytopenias, markedly elevated ferritin, persistent fevers, 96
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viral RNA genome replicates, and it is translated into and ARDS.7 The therapeutic target in COVID-19 is
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two glycoproteins and structural proteins. Finally, the aimed at inhibiting viral replication and suppressing the
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formed enveloped glycoproteins, genomic RNA, and severe inflammatory response.
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ABBREVIATIONS: COVID-19 = coronavirus disease 2019; CTL = *Collaborators from the Temple University COVID-19 Research
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cytotoxic T-lymphocyte; HIT = heparin-induced thrombocytopenia; Group are listed in e-Appendix 1.
49 HLH = hemophagocytic lymphohistiocytosis; IVIG = IV immuno- 104
CORRESPONDENCE TO: Maulin Patel, MD, Temple University Hos-
50 globulin; SARS-CoV-2 = severe acute respiratory syndrome corona- pital, 7th floor Parkinson Pavilion, 3401 N Broad St, Philadelphia, PA 105
51 virus-2 19140; e-mail: maulin.patel@tuhs.temple.edu 106
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AFFILIATIONS: From the Department of Thoracic Medicine and Copyright Ó 2020 American College of Chest Physicians. Published by
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Q2 Surgery (Drs Patel, Dmoinguez, Sacher, Desai, and Criner), Lewis Katz Elsevier Inc. All rights reserved.
53 School of Medicine at Temple University, Philadelphia, PA; the 108
DOI: https://doi.org/10.1016/j.chest.2020.09.077
54 Department of Hematology and Oncology (Drs Chandar and Brom- 109
berg), and the Department of Rheumatology (Dr Caricchio), Temple
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University Hospital, Philadelphia, PA.

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111 Some widely used cytokine storm therapies include oxygen saturation of 100% on room air. Her physical 166
112 pulse-dose steroids, sarilumab, tocilizumab (monoclonal examination was significant for bibasilar crackles. 167
113 168
antibodies against the IL-6 receptor), anakinra (anti-IL-1
114 Initial laboratory findings were significant for urinary tract 169
receptor antagonist), and various other biologic
115 infection and acute kidney injury. She was initially 170
medications. Convalescent plasma offers some benefits
116 admitted to the general medical service, and then 171
at providing passive immunity, and it may ameliorate
117 developed progressive acute hypoxic respiratory failure 172
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the malignant inflammatory process; however, a recent 173
unresponsive to progressive increase in doses of
119 study from Wuhan, China, showed no difference in 174
supplemental oxygen. The patient was then transferred to
120 outcomes vs the standard of care.8 Despite receiving 175
the ICU, where noninvasive ventilation failed and required
121 these medications, some patients progress to 176
intubation. Nasopharyngeal swab for SARS-CoV-2 was
122 multisystem organ failure and death. 177
sent and resulted as positive. She was subsequently
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Etoposide, a topoisomerase II inhibitor, has been used enrolled in a randomized placebo-controlled double-blind 179
125 successfully to treat hyperinflammatory syndromes such clinical trial for sarilumab, an anti-IL-6 drug, used to treat 180
126 as HLH, both secondary (due to viral syndromes) and cytokine storm syndrome due to COVID-19. Despite 181
127 familial types.9,10 It has been proposed that SARS-CoV-2 treatment with study drug, the patient did not show any 182
128 directly activates cytotoxic T-lymphocytes (CTLs), improvement, with continued elevation of inflammatory 183
129 which leads to cytokine release, thus augmenting the markers consistent with worsening cytokine storm. 184
130 activity of macrophages. In addition, augmented Rheumatology was consulted, who recommended a 7-day 185
131 macrophage function leads to prolonged antigen course of anakinra (anti-IL-1 receptor antagonist) and a 3- 186
132 presentation, thus not allowing CTLs to eliminate day course of IV immunoglobulin (IVIG). She initially 187
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activated macrophages. Etoposide can control the fevers, responded well to this therapy; however, she had a
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splenomegaly, cytopenias, hypertriglyceridemia, prolonged and complicated ICU course. The patient
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hypofibrinogenemia, and hyperferritinemia as seen in underwent tracheostomy for prolonged intubation and
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murine HLH models, by selectively acting to eliminate developed a ventilator-associated pneumonia. On hospital 192
138 activated CTLs and cause suppression of inflammatory day 18, the patient had worsening hypoxia along with 193
139 cytokine production.10,11 In addition to improving significant thrombocytopenia. Heparin-induced 194
140 hypercytokinemia, low-dose etoposide has also been thrombocytopenia (HIT) was suspected; HIT antibodies 195
141 shown in murine models to renew CTLs, thus allowing and serotonin assay were sent, heparin was discontinued, 196
142 elimination of activated macrophages, SARS-CoV-2- and bivalirudin was initiated. CT angiography of the 197
143 infected cells, and associated immunomodulatory thorax was performed, which confirmed our clinical 198
144 abnormalities of SARS-CoV-2 infection.11 suspicion of pulmonary embolism, found in the right lower 199
145 lobe (Fig 1). HIT antibody was indeterminate, and 200
146 Etoposide has not been reported yet as treatment for the 201
serotonin release assay resulted as negative, but because the
147 COVID-19-induced hyperinflammatory response that is 202
patient’s platelets improved with cessation of heparin, the
148 encountered in some patients, with some similar features 203
patient was treated for presumed HIT, because she also had
149 observed in HLH. Herein, we present a patient with 204
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clinical evidence of digital necrosis. It was also believed that 205
cytokine storm due to COVID-19 who received
151 the administration of IVIG had affected the HIT antibody 206
etoposide for a progressive hyperinflammatory response
152 testing. On hospital day 20, she again developed worsening 207
despite immunomodulatory therapy.
153 hypoxia, persistent fevers, and an increase in inflammatory 208
154 markers as noted in Figure 2. Bronchoscopy was 209
155 performed, which showed normal airways without 210
Case Presentation
156 purulence. Bronchial washings were negative for any acute 211
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The patient is a 66-year-old woman with a medical 212
infection; however, SARS-CoV-2 polymerase chain
158 history of type 2 diabetes (last glycosylated hemoglobin 213
reaction from the BAL fluid was positive.
159 of 6.7), hypertension, and hyperlipidemia, who was 214
160 admitted with a chief complaint of insomnia, shortness Given her deteriorating clinical status despite multiple 215
161 of breath, and malaise of 5 days’ duration. Review of immunomodulator therapies, a multidisciplinary 216
162 systems was otherwise negative, and she denied any meeting was arranged between pulmonary, 217
163 recent travel or sick contacts. Initial vital signs showed a rheumatology, and hematology to discuss further 218
164 temperature of 36.8
C, heart rate of 68 beats/min, BP of treatment options. Etoposide had previously been 219
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119/45 mm Hg, respiratory rate of 20 breaths/min, and discussed as an agent that may be effective at treating a

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234 Figure 1 – CT angiography of the thorax. A, Arrow shows right lower lobe pulmonary embolism. B, Multifocal peripheral ground-glass opacities. 289
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COVID-19-related hyperinflammatory state similar to (hyperferritinemia, cytopenia as noted by the anemia and 291
237 HLH if refractory to other available treatments. thrombocytopenia, hypertriglyceridemia, and fevers). 292
238 Alternative therapies were not available given the novelty The target treatment endpoints at initiation of therapy 293
239 of disease and limited options of largely theoretical or were a decline in biomarkers, liberation from the 294
240 experimental treatments. The readministration of ventilator, and improvement in overall clinical condition 295
241 anakinra and IVIG was not considered because the effects to allow for hospital discharge. She was started on 296
242 were only temporary, and her prognosis continued to trimethoprim-sulfamethoxazole and acyclovir for 297
243 worsen. The decision was made to give etoposide, because pneumocystis pneumonia and herpes simplex 298
244 the patient met four of the eight criteria for HLH prophylaxis respectively, along with dexamethasone 299
245 300
246 Ferritin (ng/ml) CRP (mg/dL) Temperature (F) 301
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D-dimer (ng/ml) PaO2/FiO2 ratio
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Sarilumab

Enterobacter VAP

Pulmonary embolism

Etoposide

Improvement

Sarilumab

Enterobacter VAP

Pulmonary embolism

Etoposide

Improvement

Sarilumab

Enterobacter VAP

Pulmonary embolism

Etoposide

Improvement
Anakinra/VIG

Anakinra/VIG

Anakinra/VIG

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Triglycerides (mg/dl) LDH (U/L)
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Figure 2 – Trends of laboratory and clinical markers.

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331 followed by IV etoposide once per week at 50 mg/m2. an unprecedented treatment challenge. One of the most 386
332 There was a robust clinical response to treatment with challenging aspects of COVID-19 management is 387
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etoposide and steroids, with marked improvement in controlling the damage related to cytokine storm while
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inflammatory markers and oxygenation. Per protocol, the also trying to mitigate viral replication. Although the use
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second dose was given after 7 days. The patient was noted of monoclonal antibodies directed against IL-6 receptor
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to have a mild transaminitis that subsequently resolved. and IL receptor antagonistic therapy have been under
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Trends in laboratory inflammatory markers along with investigation for the treatment of COVID-19-related 393
339 her clinical course are shown in Figure 2. The clinical cytokine storm, not much is known about the use of 394
340 radiographic changes in response to therapy are etoposide. Rojas et al12 explain that convalescent plasma 395
341 highlighted in Figure 3. provides passive immunity and antiinflammatory 396
342 cytokines, among other proteins from donors.12 397
After clinical improvement after therapy with etoposide,
343 Unfortunately, convalescent plasma was not available at 398
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she was able to be transferred out of the ICU to a long- 399
our center at the time. Moreover, a recent study showed
345 term ventilator unit within 5 days. Here the patient was 400
no improvement in time to clinical improvement within
346 liberated from the ventilator. The patient was then 401
28 days.13
347 transferred to an acute rehab unit, where she is currently 402
348 undergoing rigorous physical therapy. The patient has The rationale for using etoposide is twofold. First, 403
349 not had any readmissions or additional infections since etoposide has already been shown to be effective in 404
350 being discharged from the hospital. regulating HLH, a hyperinflammatory syndrome. It 405
351 results in a potent selective deletion of activated T-cells 406
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along with an efficient suppression of inflammatory
353 Discussion 408
cytokine production.14 Second, it has been shown to
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Because of its novelty and lack of known effective suppress RNA virus replication in in vitro studies.15 The
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therapies, the emergence of COVID-19 has introduced combination of etoposide and dexamethasone also has
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383 Figure 3 – Chest radiograph progression for patient 1. A, Day 1, showing diffuse bilateral interstitial and airspace opacities throughout both lungs with 438
384 a basilar predominance. B, Day 8, with improved interstitial/airspace opacities. C, Day 14, increased infiltrate on right lung base. D, Day 20, worsening 439
patchy opacities with basilar predominance. E, Day 26, improvement in opacities 5 days after receiving etoposide. F, Day 29, continued improvement in
385 440
opacities after etoposide.

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441 been shown to be successful in the treatment of References 496
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443 https://coronavirus.jhu.edu/map.html. Accessed April 28, 2020. 498
viral illnesses such as severe swine flu A/H1N1, and
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avian influenza A/H5N1 infections.16,17 In addition, our Manson JJ. COVID-19: consider cytokine storm syndromes and
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450 inflammatory markers and oxygen requirements after 4. Li X, Geng M, Peng Y, Meng L, Lu S. Molecular immune 505
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451 Q6 administration of etoposide and dexamethasone. 102-108. 506
452 5. Huang C, Wang Y, Li X, et al. Clinical features of patients infected 507
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454 509
455
dependent side effect profile. Reactive cytopenias are a 6. Wong CK, Lam CWK, Wu AKL, et al. Plasma inflammatory 510
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457 the patient. The dose used in the patient is typically not 7. Seguin A, Galicier L, Boutboul D, Lemiale V, Azoulay E. Pulmonary 512
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459 potential adverse reaction with etoposide, and a mild 514
460 8. Chen C, Zhang XR, Ju ZY, He WF. Advances in the research of 515
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461 second dose. The susceptibility for developing further and the corresponding immunotherapies. Zhonghua Shao Shang Za 516
462 Zhi. 2020;36(6):471-475. 517
hematologic malignancies after etoposide administration
463 9. Lehmberg K, Nichols KE, Henter JI, et al. Consensus 518
should also be considered.9 recommendations for the diagnosis and management of
464 hemophagocytic lymphohistiocytosis associated with malignancies. 519
465 To our knowledge, this is the first case report about the Haematologica. 2015;100(8):997-1004. 520
466 use of etoposide as treatment for COVID-19. We want 10. Bergsten E, Horne AC, Aricó M, et al. Confirmed efficacy of 521
467 to highlight that this is a salvage therapy and should not etoposide and dexamethasone in HLH treatment: long-term results 522
of the cooperative HLH-2004 study. Blood. 2017;130(25):2728-2738.
468 be used first line. In our health care system to date, we 11. Takami A. Possible role of low-dose etoposide therapy for
523
469 have cared for more than 1,500 patients with COVID- hemophagocytic lymphohistiocytosis by COVID-19. Int J Hematol. 524
470 2020;112(1):122-124. 525
19, yet etoposide has only been used successfully in one
471 12. Rojas M, Rodríguez Y, Monsalve DM, et al. Convalescent plasma in 526
patient. At our institution, the use of etoposide is Covid-19: possible mechanisms of action. Autoimmun Rev.
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approved only after a multidisciplinary team of 2020;19(7):102554.
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hematologists, rheumatologists, and pulmonologists 13. Li L, Zhang W, Hu Y, et al. Effect of convalescent plasma therapy on
474 time to clinical improvement in patients with severe and life- 529
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reach a consensus agreement. The decision to administer threatening COVID-19: a randomized clinical trial. JAMA. 530
476 etoposide should be made on a case-by-case basis and 2020;324(5):460-470.
531
477 should be considered for a subset of patients who are 14. Johnson TS, Terrell CE, Millen SH, Katz JD, Hildeman DA, 532
Jordan MB. Etoposide selectively ablates activated t cells to control
478 severely ill but with potential for recovery. In this the immunoregulatory disorder hemophagocytic 533
479 emerging and rapidly changing clinical environment, we lymphohistiocytosis. J Immunol. 2014;192(1):84-91. 534
480 will continue to follow the progress of the patients, and 15. Lovetrue B. The AI-discovered aetiology of COVID-19 and rationale 535
of the irinotecan þ etoposide combination therapy for critically ill
481 we invite others to share their experiences with 536
COVID-19 patients [Published online ahead of print August 15,
482 etoposide as well. In closing, randomized controlled 2020]. Med Hypotheses. 2020. https://doi.org/10.1016/j.mehy.2020. 537
483 110180. 538
trials18 are needed to evaluate the overall usage and
484 16. Henter JI, Palmkvist-Kaijser K, Holzgraefe B, Bryceson YT, 539
efficacy of etoposide for the treatment of cytokine storm Palmér K. Cytotoxic therapy for severe swine flu A/H1N1. Lancet.
485 2010;376(9758):2116. 540
due to COVID-19.
486 17. Henter JI, Chow CB, Leung CW, Lau YL. Cytotoxic therapy for 541
487 severe avian influenza A (H5N1) infection. Lancet. 2006;367(9513): 542
Acknowledgments 870-873.
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Q9 Q7 Financial/nonfinancial disclosures: None declared.
489 18. National Institutes of Health Clinical Center. A phase II single- 544
Other contributions: CHEST worked with the authors to ensure that center, randomized, open-label, safety and efficacy study of
490 etoposide in patients with COVID-19 infection. NCT04356690. 545
the Journal policies on patient consent to report information were met.
491 ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 546
Additional information: The e-Appendix can be found in the 2020. http://clinicaltrials.gov/ct2/show/ NCT04356690. Updated
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Supplemental Materials section of the online article. September 4, 2020.
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