Where Are the Antibodies? A Case of Prolonged COVID19 Infection in an Immunocompromised Patient Status Post Rituximab Therapy

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Immunocompromised patients treated with Rituximab remain highly vulnerable to COVID19infection, demonstrating high rates of mortality. Herein, we report a case of persistent COVID19 infection in a patient treated with immunosuppresion secondary to Rituximab. A 34-year-old male with a history of vaping and stage IVB follicular lymphoma (completing rituximab therapy 3 months prior to initial presentation), presented with dyspnea, fever, and cough. Patient was initially treated at an outside institution for community acquired pneumonia and sinusitis with antibiotics (blood and respiratory samples from bronchoalveolar lavage (BAL) were negative, including COVID19).Patient was discharged after 6 days. He was readmitted 5 days later (11 days from initial presentation) for respiratory failure, and underwent repeat bronchoscopy, which revealed a positiveCOVID19 PCR. He was treated with dexamethasone, declined remdesivir, and was discharged after 4 days (15 days from initial presentation). Over the next 6 weeks (weeks 2-8 from initial presentation), he was readmitted twice for recurrent respiratory symptoms and was treated with Remdesivir, systemic steroids, and trimethoprim-sulfamethoxazole for pneumocystis prophylaxis. Extensive workup for infection, autoimmune disease, and lymphoma recurrence was unrevealing. He was discharged on oxygen. He was again readmitted for COVID19 pneumonia 2 weeks later(10 weeks from initial presentation) and treated with remdesivir, high dose steroids, and antibiotics. IgG level was reduced at 346 mg/dL . COVID19 anti-nucleocapsid IgG was negative. At the moment of presentation, emergency authorization for monoclonal antibodies against COVID had been lifted, so intravenous immunoglobulin (IVIG) and nirmatrelvir-ritonavir were initiated. Patient achieved significant improvement soon thereafter, being weaned off of oxygen within 48 hours of IVIG. He was discharged after 10 days (almost 12 weeks after initial presentation) on a 1 month course of nirmatrelvir-ritonavir, steroid taper, and trimethoprim-sulfamethoxazole. In office follow up one month later (16 weeks after initial presentation), his symptoms had almost completely resolved.COVID19 nasal PCR was finally negative and Anti-spike IgG was positive. This case outlines the risk for severe COVID that patients undergoing anti-CD20 therapy are exposed to. Our patient seemed to have recurrent/subacute COVID infection, partly due to lack of humoral immunity. Checking for immunoglobulin levels in these patients and providing IVIG replacement if they are deficient may impact their outcomes positively. This case highlights the importance of tailoring therapeutic approaches for immunocompromised patients with COVID19 not responding to standard therapies. Further investigation is needed to clarify the role of extended nirmatrelvir-ritonavir treatment in such cases.

Volume

209

Issue

Suppl

First Page

A1348

Comments

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

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A1348

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