Role of Intravenous Immunoglobin in an Immunocompromised Patient With Prolonged COVID Pneumonia

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Rituximab reduces immunoglobulin levels and causes B-cell depletion. It dampens the humoral immune response, and may complicate the course of COVID disease in immunocompromised patients. A 34 year old male with history of follicular lymphoma, currently in remission, presented to the hospital with complaint of dyspnea, fatigue, unremitting cough and pseudohemoptysis. He was admitted to another hospital twice over the past month, with similar presentation, where he tested positive for COVID-19. He was treated for superimposed bacterial pneumonia, however his symptoms persisted. Chest xray revealed bilateral patchy interstitial infiltrates. He also underwent bronchoscopy for suspected mucus plug and his infectious workup from the bronchoalveolar lavage (BAL), including gram stain and culture, mycobacteria, fungal studies and aspergillus were negative. For follicular lymphoma he was treated with bendamustine followed by rituximab infusion for maintenance of remission. His labs were significant for leukopenia to 3.4 bil/L, elevated CRP and ESR to 238 and 76 respectively. Patient received treatment with high dose dexamethasone and remdesivir therapy for acute hypoxic respiratory failure secondary to presumed COVID pneumonia. His oxygen requirements improved prior to discharge. Of note, CRP also trended down 2-3 days after steroid therapy. However, two weeks later patient was admitted again, with worsening hypoxia, increased work of breathing and pleuritic chest pain. CRP was elevated to 250. He was treated with empiric antibiotics for pneumonia. Chest CT scan showed persistent and increased ground glass and consolidative opacities bilaterally in the upper and lower lung zones (image). He underwent bronchoscopy. Surgical lung biopsy was considered, but deferred by thoracic surgery given high risk for procedure. Flow cytometry from the BAL sample revealed virtually absent B-cells, T-cells (88% of lymphocytes) had a CD4:CD8 ratio of 1.2:1 without immunophenotypic aberrancy. Other infectious workup including aspergillus stain, antigen for Blastomyces, Coccidioides, histoplasma, AFB smear and gram stain, culture were negative. He was started on solumedrol therapy with prolonged steroid taper on discharge. He was admitted again about a month later with similar presentation. His immunoglobulin levels showed low Ig G level at 240 mg/dL. He was treated with remdesivir and also received intravenous immunoglobulin therapy for hypogammaglobinemia. His inflammatory markers dramatically improved after IVIG, steroid and antiviral therapy. Follow-up CT scan outpatient showed remarkable improvement in his chest infiltrates at 6 weeks. The role of IVIG therapy in immunocompromised patients remains controversial. The efficacy of therapy particularly in COVID patients may be related to the disease severity

Volume

209

Issue

Suppl

First Page

A4177

Comments

International Conference of the American Thoracic Society, May 17-22, 2024, San Diego, CA

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A4177

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