PROLONGED COVID-19 INFECTION IN AN IMMUNOSUPPRESSED PATIENT TREATED WITH CASIRIVIMAB/IMDEVIMAB

ABSTRACT

SESSION TITLE Drug-Induced Critical Care SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: We present a case of an immunosuppressed patient on rituximab who developed prolonged COVID-19 infection lasting over 6 months. CASE PRESENTATION A 61-year-old male with a history of follicular lymphoma in remission on maintenance rituximab was hospitalized in December 2020 due to COVID-19 pneumonia. Chest X-ray demonstrated patchy bilateral airspace disease. He was treated with dexamethasone and remdesivir. His symptoms did not resolve upon discharge and in January 2021, he was referred to outpatient pulmonology with fevers, progressive dyspnea, and hypoxemia requiring 2 liters oxygen with activity. Computed tomography (CT) of the chest exhibited worsening bilateral ground-glass opacities compared to previous imaging. He had a bronchoscopy in February 2021 which showed negative cultures, except for persistent positive COVID-19 by PCR. He was subsequently started on a prednisone taper for presumed post-COVID-19 organizing pneumonia. Starting from February to May, he would have improvement in his fevers and dyspnea with high dose steroids, but worsening of symptoms with tapering of the dosage requiring two hospital admissions. During these admissions, he was treated with remdesivir and intravenous (IV) steroids, and discharged on steroid tapers. He also had two bronchoscopies in April and May that were positive for COVID-19 by PCR but otherwise had negative cultures. Serum COVID-19 anti-spike antibodies were also noted to be negative, while he remained positive for COVID-19 by nasal swab. With the lack of improvement with treatment for post-COVID-19 organizing pneumonia, Regeneron was trialed under the compassionate use guidelines for working diagnosis of persistent COVID-19 infection. He reported resolution of fevers, improvement in fatigue, and decreased oxygen requirements within 1 week of Regeneron administration. At 3 month follow up, his oxygen requirements were 1 liter with activity, he was afebrile, and COVID-19 anti-spike antibodies remained present. DISCUSSION: Medications such as rituximab diminish the immune system's ability to produce neutralizing antibodies to COVID-19 and may lead to a prolonged course of infection (1). Other case studies have demonstrated improvement with Regeneron in immunosuppressed patients (1, 2). CONCLUSIONS: We present a case of prolonged COVID-19 infection in the setting of immunosuppression while on maintenance rituximab for follicular lymphoma in remission. We believe this patient's case represents persistent COVID-19 infection and not re-infection due to persistent positive COVID-19 PCR, fevers, and absence of COVID-19 antibodies. This patient demonstrated dramatic improvement in his symptoms after Regeneron infusion. Monoclonal antibodies should be considered beyond accepted treatment windows in immunocompromised patients with prolonged COVID-19 symptoms. Reference #1 Velez I, Bermejo J, Perez J, Aguayo L, Ruiz M, Garcia-Erce J. Two patients with rituximab associated low gammaglobulin levels and relapsed COVID-19 infections treated with convalescent plasma. https//doi.org/10/1016/j.transcri.2021.103104 Reference #2 D'Abramo A, Vita S, Maffongelli G, Mariano A, Agrati C, Castilletti C, et al. Prolonged and Severe SARS-CoV-2 infection in patients under B-cell-depleting drug successfully treated A tailored approach. Internal Journal of Infectious Diseases 2021;107 247-250 DISCLOSURES No relevant relationships by Joseph Pitcher No relevant relationships by Subhan Toor