1
INTRODUCTION
Coronavirus disease 2019 (COVID‐19) is a viral respiratory infection caused by severe
acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) that varies from asymptomatic
to severe illness and death.
1
,
2
Old age, hypertension, obesity, diabetes, cardiovascular disease, chronic lung disease,
and cancer predict a severe course, risk of hospitalization, and death.
1
,
2
The US Food and Drug Administration recently approved remdesivir for the treatment
of COVID‐19 patients requiring hospitalization.
3
However, high mortality persists despite use of remdesivir.
3
,
4
Remdesivir inhibits SARS‐CoV‐2 RNA polymerase, hindering viral replication.
5
In patients with COVID‐19, peak SARS‐CoV‐2 concentrations occur on Day 5 and most
active replication in the throat during the first 5 days of symptoms onset.
6
In rhesus macaques infected with SARS‐CoV‐2 and Middle East respiratory syndrome coronavirus,
best outcomes were obtained when remdesivir was started early, at 12 h of inoculation.
7
,
8
These observations suggest that inhibiting viral replication with remdesivir would
be more effective if started early after symptoms development. We here report our
experience using an early treatment strategy in a high‐risk patient with COVID‐19
who within 48 h of symptoms onset received remdesivir and experienced an immediate
and remarkable clinical response to full recovery.
2
CASE PRESENTATION
A 77‐year‐old Caucasian male presented on October 24, 2020, with antigen and polymerase
chain reaction proven COVID‐19 infection, following a 2‐day course of frontal headaches,
nasal congestion, myalgia, dry cough, lower lip paresthesia, and temperatures of 37.7–38.9°C
treated with ibuprofen. The patient's history included atherosclerotic heart disease,
exertional non‐sustained ventricular tachycardia, hypertension, hyperlipidemia, toxin‐positive
Clostridioides difficile diarrhea, prostate cancer, and radical prostatectomy. Physical
exam revealed a nontoxic, lean patient, in no distress, with normal heart and lung
auscultation and pulse oximetry of 96%. When compared with laboratory data obtained
the day prior, repeat labs showed a decrease in total neutrophil count (from 2810
to 1190 cells/µl), persistent mild lymphocytopenia, thrombocytopenia, and an elevated
C‐reactive protein, normal d‐dimer, ferritin, and procalcitonin level (Table 1). The
chest x‐ray and 12‐lead electrocardiogram were reportedly normal.
Table 1
Time and dose of remdesivir administration and laboratory values before, during and
after hospitalization in a patient who tested positive for COVID‐19 on 10/23/2020
07/21
10/23
10/24
10/25
10/26
10/27
11/11
11/20
Outpatient
5 p.m.
4 p.m.
7 a.m.
6 a.m.
8 a.m.
1 p.m.
1 p.m.
Labs drawn
ER
Hospital
Hospital
Hospital
Hospital
Outpatient
Outpatient
Remdesivir administration
200 mg
100 mg
100 mg
100 mg
8 p.m.
7 p.m.
7 p.m.
4 p.m.
WBC (cells/µl)
4700
4640
3290
3930
3320
3270
4500
Platelet (K/µl)
223
139
143
137
146
169
199
Lymphocytes (cells/µl)
1753
860
1290
2200
2210
2360
1976
Monocytes (cells/µl)
456
930
800
790
510
480
423
Neutrophils (cells/µl)
2383
2810
1190
910
580
400
2025
Eosinophils (cells/µl)
89
<30
<30
<30
<30
<30
59
Basophils (cells/µl)
19
<30
<30
<30
<30
<30
18
Hemoglobin (g/dL)
13.9
12.7
12.6
12.8
13.4
14.3
13.5
RDW (%)
13.3
12.7
12.8
12.9
13.0
13.0
12.7
Respiratory panel PCR
Neg
Blood Cultures
Neg
Neg
Alkaline‐Phosphatase (U/L)
69
68
65
62
64
64
AST (U/L)
18
18
21
19
21
17
ALT (U/L)
15
13
14
15
Sr. Cr (mg/dL)
0.99
1.14
1.17
1.05
0.94
0.85
CRP (mg/dL)
0.8
0.2
0.4
d‐Dimer (ng/mL)
320
290
Ferritin (ng/ml)
186
216
335
194
Pro‐calcitonin (ng/mL)
0.07
<0.06
ESR (mm/hr)
7
6
Anion Gap (mmol/L)
12
9
8
10
9
Troponin T (ng/ml)
<0.01
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; COVID‐19,
coronavirus disease 2019; CRP, C‐reactive protein; ESR, erythrocyte sedimentation
rate; PCR, polymerase chain reaction; RDW, red cell distribution width; WBC, white
blood cell.
John Wiley & Sons, Ltd.
This article is being made freely available through PubMed Central as part of the
COVID-19 public health emergency response. It can be used for unrestricted research
re-use and analysis in any form or by any means with acknowledgement of the original
source, for the duration of the public health emergency.
3
CLINICAL COURSE
Because of the age and clinical risk factors, the patient was admitted for further
observation and management. The first dose of remdesivir 200 mg was administered at
approximately 8 p.m., 48‐h after symptom onset, followed by a daily intravenous dose
of 100 mg for three additional days (Table 1). In addition, he received 40 mg of enoxaparin,
losartan 50 mg daily, and benzonate as needed. By the second dose of remdesivir (24‐h
later), the symptoms had markedly improved, as evidenced by the absence of any further
fever, chills, weakness, headaches, or muscle aches. Pulse oximetry at room air remained
at 96%–99% and unchanged with brisk ambulation. Persistent neutropenia ensued with
normalization of lymphocytes, platelet, monocytes, and C‐reactive protein levels.
There were no changes in aspartate aminotransferase, alanine aminotransferase, alkaline
phosphatase. Because of the excellent clinical course, the fifth dose of remdesivir
was withheld, and the patient was discharged home after 3 days. The patient remained
in isolation at home for an additional 7 days. During this time, he was asymptomatic,
afebrile, and able to walk long distances and upstairs without dyspnea, reporting
only mild tiredness, minimal cough, and residual lower‐lip paresthesia that resolved
entirely by Day 10. Laboratory results from 2 and 3 weeks later confirmed normalization
of all blood counts. The neutropenia, which started before the first‐dose of remdesivir,
most likely resulted from an idiosyncratic reaction to ibuprofen.
4
DISCUSSION
Although no meaningful conclusion can be drawn from a single case, the observation
that early use of remdesivir in our COVID‐19 patient with high‐risk features resulted
in immediate resolution of symptoms, early discharge and prompt recovery of daily
activities, is worth further consideration. Our case report is consistent with data
in influenza patients where inhibition of viral replication with oseltaminir (Tamiflu®)
achieves best clinical benefits when administered within 2 days of symptom onset.
9
Treatment initiation within 48 h of the onset of symptoms may be responsible for the
excellent response to remdesivir. Failure to inhibit viral replication at its peak
time may allow disease progression, where virus‐induced tissue damage, abnormal immunomodulation
and inflammation, become determinants of the patient outcomes. We propose that delayed
treatment initiation is at least partly responsible for the reported modest therapeutic
response of remdesivir.
2
,
10
While blanket use of remdesivir in COVID‐19 positive subjects is neither desirable
nor expectedly cost‐effective, in higher‐risk patients, early inhibition of viral
replication may be clinically impactful and lifesaving. Future studies comparing the
effect of time‐to‐treatment (illness onset to first dose of remdesivir) in this subset
population are much needed. Until then, early remdesivir administration among high‐risk
patients should be considered.
5
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
AUTHOR CONTRIBUTIONS
All authors materially participated in the research, data collection and article preparation.
Luigi X. Cubeddu and Robert J. Cubeddu approved the final article.
ETHICS STATEMENT
Written informed consent was obtained from the patient for publication of this case
report and accompanying table.