Undetectable SARS-CoV-2 active adaptive immunity-post-vaccination or post-COVID-19 severe disease-after immunosuppressants use.

Since the beginning of COVID-19 vaccination in New Jersey in December 2020, we have observed multiple cases of undetectable adaptive immunity, post-vaccination or post-COVID-19 infection, in patients using immunosuppressants. Here, we present three cases of patients using immunosuppressants: mycophenolate and tacrolimus for renal transplant; ocrelizumab for multiple sclerosis and rituximab for peripheral ulcerative keratitis. All three patients were admitted for acute respiratory distress syndrome (ARDS) from COVID-19 pneumonia; two patients reported having received full COVID-19 vaccination prior to admission and one unvaccinated patient required readmission. Our findings showed that these patients tested negative for SARS-CoV-2 IgM spike and CoV-2 IgG nucleocapsid antibodies. All three patients were treated with standard-of-care remdesivir, dexamethasone and convalescent plasma; two recovered successfully and one patient died from respiratory failure secondary to worsening ARDS from COVID-19 pneumonia. We highlight the challenges of treating immunosuppressed patients with COVID-19 pneumonia, in an era where dissemination of such information is paramount to helping doctors standardise and improve the quality of care for these patients.

Stress-induced cardiomyopathy.

A woman in her early 70s presented with chest pain, dyspnoea and diaphoresis 30 min after her husband expired in our hospital. Cardiac markers were elevated and there were acute changes in ECG suggestive for acute coronary syndrome. Echocardiogram showed apical akinesis, basal segment hyperkinesis with an ejection fraction of 30%. Cardiac catheterisation was performed showing non-obstructive coronary arteries, leading to the diagnosis of stress-induced cardiomyopathy. The patient improved with medical management. Repeat echocardiogram 2 months later showed resolution of heart failure with an ejection fraction of 65-70%.