RELAPSE AND REMITTING COVID-19 INFECTIONS IN AN IMMUNOSUPPRESSED PATIENT ON CHRONIC RITUXIMAB INFUSIONS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The rapid spread of SARS-CoV-2 has resulted in an ongoing pandemic that continues to plague the world. In those exposed naturally to Covid-19, an antibody response is expected. However, we present a case of an immunocompromised patient who developed recurring COVID-19 infection due to an inadequate humoral response. CASE PRESENTATION: A 45-year-old female with hypothyroidism and Wegener's Granulomatosis on chronic prednisone, methotrexate, and bi-annual Rituximab was admitted with complaints of shortness of breath, fevers, and a positive PCR for SARS-Cov-2. Chest X-ray (CXR) demonstrated development of bilateral basilar airspace disease. Patient remained stable on room air, and was subsequently discharged.Over the next several weeks, she was admitted four more times for similar symptoms, a positive PCR, and a CXR with progressively worsening bilateral patchy alveolar/interstitial opacities. During the 2nd admission, patient received IV steroids and empiric IV antibiotics. She improved, and was discharged on PO antibiotics, steroids, and oxygen. However, patient was readmitted 3 days later. During this admission, patient was given IV immunoglobulin (IVIG) G due to concern for secondary humoral deficiency (IgG of 551 mg/dl, IgM of 15.8 mg/dl, & IgA of 56.3 mg/dl) from chronic rituximab. Patient improved and was discharged with a course of steroids.During her 4th admission she received her second dose of IVIG. On her 5th admission, she was hospitalized for 13 days and underwent extensive work-up and treatment. Other concomitant infections, obtained via serum, sputum, and bronchoscopy with bronchoalveolar lavage, were negative.SARS-CoV-2 total antibodies obtained from serum samples were non-reactive. Although IgA and IgM levels remained low, patient's IgG levels were elevated to 1959 mg/dl after two sessions of IVIG. Patient had gradual improvement of symptoms and was discharged home.She had no further admissions, but did require intermittent oxygen on exertion. She finally tested negative for SARS-CoV-2 seven months from her last admission, and was discontinued from Rituximab. DISCUSSION: Various studies have shown that Rituximab is associated with low IgG levels and severe COVID-19 infection. This unique case illustrates a relapsing COVID-19 infection in the setting of a patient on Rituximab. It demonstrates how patients diagnosed with COVID-19 on Rituximab likely need closer follow-up upon discharge. It also highlights potential efficacy of measuring Ig levels and utilizing IVIG as treatment in patients with an inadequate humoral response. CONCLUSIONS: Although one cannot draw definitive conclusions in regards to Rituximab based solely off this observation, this case demonstrates the necessity of continuing to study the long-lasting impact of rituximab in relation to COVID-19, as well as other viral illnesses, to better direct both inpatient and outpatient care. REFERENCE #1: Wu, J., Liang, B., Chen, C. et al. SARS-CoV-2 infection induces sustained humoral immune responses in convalescent patients following symptomatic COVID-19. Nat Commun 12, 1813 (2021). REFERENCE #2: Avouac J, Drumez E, Hachulla E, et al. COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases treated with rituximab: a cohort study [published online ahead of print, 2021 Mar 25]. Lancet Rheumatol. 2021 REFERENCE #3: Emilio. Low immunoglobulin levels increase the risk of severe hypogammaglobulinemia in granulomatosis with polyangiitis patients receiving rituximab. BMC musculoskeletal disorders vol. 17 6. 6 Jan. 2016 DISCLOSURES: No relevant relationships by Derrick Cleland, source=Web Response No relevant relationships by sahib grewal, source=Web Response No relevant relationships by Kanwaljeet Maken, source=Web Response