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We have read with interest the excellent review by McGonagle et al. discussing the possible role of hyperinflammation secondary to macrophage activation syndrome (MAS) or cytokine storm also known as secondary haemophagocitic lymphohistocytosis (sHLH) in the immunopathology of severe COVID-19 pneumonia [1]. High levels of interleukin-6 (IL-6) associated with poor outcome in the setting of COVID-19 pneumonia evoked the use of tocilizumab (an IL-6 receptor monoclonal blocking agent) approved for the treatment of rheumatoid arthritis in Japan (2008), Europe (2009) and USA (2010)[2–5]. The drug has been approved in China for COVID-19 pneumonia and elevated IL-6 (ChiCTR2000029765) and in Italy, following the outbreak that involved our country from February 21, it was extensively used offlabel before the Italian Regulatory Agency of Drug (AIFA, Agenzia Italiana del Farmaco) approved a …