M413 COVID-19 IN A PATIENT WITH CVID AND CONTRAINDICATIONS TO SEVERAL POTENTIAL TREATMENTS

Abstract

Despite nearly 18 million cases of SARS-CoV-2 thus far, there is minimal information regarding treatment in patients with common variable immunodeficiency (CVID), such as presented here. A 59-year-old male with CVID was receiving IVIG infusion when RN noted lethargy, fever, and cough. Chest Xray showed bilateral lower lobe opacities. Labs significant for lymphopenia to 0.5, CRP 4.9, CK 23, ESR 22. SARS-CoV-2 testing positive. Given history of atrial fibrillation, hypertension, severe back pain, and 10.5-pack-year smoking history, patient requested to be DNR/DNI. Patient eventually required high flow oxygen with 70% FiO2 at 35L/min. Hydroxychloroquine initiated, but Qtc became prolonged. He received vitamin C and enrolled in convalescent plasma trial. Patient’s respiratory status worsened with increasing hypoxia. D-dimer increased to 7.63, ferritin to 2862, and LDH to 533. Prone position poorly tolerated. BiPAP recommended, but patient increasingly anxious and declined, requesting to go home to die. Within 2 days of receiving plasma, mentation improved; within 9 days oxygen requirements decreased; discharge occurred after 24 days in the hospital. Patient subsequently admitted for severe back pain and found to be still SARS-CoV-2 positive, 8.5 weeks from initial test. However, he continued asymptomatic on room air with improved chest xray. This patient had contraindications to several potential medications, physical limitations with proning, and slow recovery after receiving convalescent plasma, though he did not require ventilator support. There was evidence of hyperinflammation secondary to COVID-19, and it is unknown to what degree immunodeficiency may have been protective against a severe cytokine storm. Further investigation necessary.