A Case Report on a Chemotherapy Treatment to a SARSCOV2 PCR Positive, Non-Hodgkins Lymphoma Filipino Patient

Abstract

SARSCOV2 causing the COVID-19 infection has spread to a pandemic scale and putting the vulnerable population at risk of infection such as those with malignancies. Cancer treatment remains to be controversial in this time of pandemic such that recommendations were either delay treatment, reduce hospital exposure, or to balance the risk of disease progression(e.g. malignancy) and acquiring the disease (COVID-19). Information on COVID-19 positive cancer patients receiving chemotherapy remains to be limited. Thus, this case is reported. The case is a 64 year old male, newly diagnosed, Non-Hodgkins lymphoma who presented with severe anemia and weight loss. He was diagnosed through the bone marrow findings of CD20, Ki67, BCL2 positive B cell Non-Hodgkins lymphoma, NOS. He underwent induction chemotherapy with Prednisone, Cyclophosphamide and Vincristine. Thereafter he diagnosed to have COVID-19 infection, moderate. He remained to be PCR positive but with noted negative IgM Antibody. He showed signs of worsening anemia thus was given succeeding chemotherapy while admitted in the COVID unit of the hospital. Malignancy in general poses greater risk of severe infection with COVID-19 and possibly a worse outcome.8 The decision to proceed with chemotherapy treatment at the time when cases in the Philippines were not clear due to few testing capacity in the different institutions was based on the symptomatic persistence of severe anemia and weight loss as well as reduction in the functional capacity of the patient. The focus of efforts of oncologists and hematologists as recommended by their respective societies was on the reduction of the possibility of acquiring COVID-19 infection. There is paucity of data among those patients who have been diagnosed with COVID-19 and was given chemotherapy. Although, several studies have shown that among patients with COVID-19 and cancer as co-morbidity, the mortality can reach as high as 21% to 33% or can present with severe type of infection. Recommendations given by National Cancer Center Network(NCCN), American Society of Clinical Oncology(ASCO), European Society for Medical Oncology(ESMO, National Institute for Health and Care Excellence(NICE), World Health Organization(WHO), and Center for Disease Control(CDC) consistently revolve around the shifting of follow-up consults via teleconsultation to reduce travel to the hospital, delay or reduction of immunosuppressive treatments if possible, careful and holistic, multidisciplinary individualized approach in chemotherapeutic treatment, and withholding chemotherapy once positive with SARSCOV2 PCR positive test. In this case, the patient remained to be asymptomatic, non-oxygen requiring but remained to be positive on his 3rd PCR test done (20 days from initial positive test). The infectious disease service considered this as a false positive test and only a reflection of SARSCOV2 RNA remnants in the patient's upper airway. The clinical presentation of this cancer patient to the COVID infection is contradictory to those seen in most studies reviewed. Based on the limited knowledge on the pathophysiology of COVID-19, hyperinflammatory response occur in a robust immune system that causes Systemic inflammatory response syndrome(SIRS) and cytokine storm or hypoinflammatory response leading to multiple secondary bacterial infection.10 But neither was seen in this case. It is therefore possible that details of the mechanism of COVID-19 infection and its association with co-morbidities (malignancy) to severity are yet to be elucidated. All of the knowledge that is learned in this time of pandemic stems from a continuous trial and error efforts of clinicians who, through a sound theoretical foundation, first hand clinical experience and outcome endlessly refine approaches to produce the best outcome for those who are infected with the virus, most importantly, to the vulnerable population, such as those who is burdened by malignancies and COVID-19 infection. The treatment of COVID-19 positive patients with hematologic malignancy should be individualized and should focus on the balance between disease severity and risk of worsening COVID-19 infection.