DISSEMINATED HERPES ZOSTER VIRUS INFECTION FOLLOWING BARICITINIB IN COVID-19

ABSTRACT

SESSION TITLE COVID-19 Co-Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Baricitinib with Remdesivir has been Food and Drug Administration (FDA) approved for hospitalized COVID-19 pneumonia patients requiring supplemental oxygen and is used across the United States. However, limited post-marketing surveillance data is currently available for these drugs. We present a case of an unvaccinated, immunocompetent patient with Herpes-Zoster virus (HZV) infection following baricitinib administration. CASE PRESENTATION A 66-year-old African-American male with unknown vaccination status for Herpes zoster presented with worsening shortness of breath for 1 week. He had an SpO2 85% on presentation however had to be subsequently intubated due to worsening hypoxia in the ER. Cardiorespiratory exam was remarkable for diminished bibasilar breath sounds. Lab work was significant for positive COVID-19, elevated leukocytes and deranged inflammatory markers. CT chest showed bilateral ground glass opacities. He received a 14 day course of baricitinib, 10 days of dexamethasone and 5 days of remdesivir during his hospital stay. Tracheostomy and percutaneous endoscopic gastrostomy were performed due to prolonged vent dependence. On day 37 of hospitalization, the patient developed vesicular rashes over his left shoulder and anterior chest. Disseminated HZV infection was confirmed based on serologic testing. Patient received 7 days of valacyclovir with complete resolution. He was eventually discharged to a pulmonary rehabilitation center. DISCUSSION: Baricitinib was first developed for patients with rheumatoid arthritis and has been used in the treatment of rheumatoid arthritis and acts by reversible inhibition of JAK1 and JAK2. These proteins have been implicated in COVID-19 pathophysiology;promoting intracellular assembly of SARS-CoV-2 and subsequent cytokine release. Baricitinib in COVID-19 leads to the inhibition of proinflammatory cytokine release, antibody production, monocyte activation and viral proliferation. [1] There have been several studies published in support of Baricitinib induced HZV infection in rheumatoid arthritis patients, however there is little data available in COVID patients. Nonetheless, immunomodulatory action is the same. A study comparing the incidence rate (IR) of Baricitinib emergent HZV infection per 100 patient years (PY) vs placebo found IR/100PY 4.3 (p<_0.01) vs 3.1 (p not significant) [2]. Another study found the HZV IR vs placebo of 4.3 vs 1.0, with all-bari-RA IR was 3.2 (95% CI 2.8-3.7) [3]. In our case, the patient developed HZV infection after baricitinib treatment, demonstrating its immunomodulatory effects. CONCLUSIONS: This case demonstrates the ability of baricitinib to cause immunosuppression and hence causing HZV infection in COVID-19 affected patients. Reference #1 Schwartz DM, Bonelli M, Gadina M, O'shea JJ. Type I/II cytokines, JAKs, and new strategies for treating autoimmune diseases. Nat Rev Rheumatol. 2016;12(1)25. Reference #2 Kevin L, Masayoshi H, Mark C et al. Infections in baricitinib clinical trials for patients with active rheumatoid arthritis. Ann Rheum Dis.2020 Oct;79(10)1290-1297. Reference #3 Joseph S, Mark C, Tsutomu T et al. Safety profile of Baricitinib in patients with active rheumatoid arthritis with over 2 years median time in treatment. The Journal of Rheumatology January 2019, 46 (1) 7-18;DOI https//doi.org/10.3899/jrheum.171361 DISCLOSURES No relevant relationships by Mark Aloysius No relevant relationships by Gursharan Kaur No relevant relationships by Mohammed Musa Najmuddin No relevant relationships by mashu shrivastava