Successful treatment of SARS-CoV-2 in an immunocompromised patient with persistent infection for 245 days: A case report
Victoria Overbeck,
Bradford P. Taylor,
Jacquelyn Turcinovic,
Xueting Qiu,
Beau Schaeffer,
Scott Seitz,
Scott R. Curry,
William P. Hanage,
John H. Connor,
Krutika Kuppalli
Affiliations
Victoria Overbeck
Departments of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, MA, USA
Bradford P. Taylor
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
Jacquelyn Turcinovic
Department of Microbiology, Boston University School of Medicine, Boston, MA, USA; National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, USA; Program in Bioinformatics, Boston University, Boston, MA, USA
Xueting Qiu
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
Beau Schaeffer
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
Scott Seitz
Department of Microbiology, Boston University School of Medicine, Boston, MA, USA; National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, USA
Scott R. Curry
Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
William P. Hanage
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
John H. Connor
Department of Microbiology, Boston University School of Medicine, Boston, MA, USA; National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, USA; Program in Bioinformatics, Boston University, Boston, MA, USA; Corresponding author. National Emerging Infectious Diseases Laboratories, 620 Albany Street, Boston, MA, 02118, USA.
Krutika Kuppalli
Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA; Corresponding author. MUSC Rutledge Tower, 135 Rutledge Avenue, 1209 MSC Code 752, Charleston, SC, 29425, USA.
Background: Immunocompromised patients receiving B-cell-depleting therapies are at increased risk of persistent SARS-CoV-2 infection, with many experiencing fatal outcomes. We report a successful outcome in a patient with rheumatoid arthritis (RA) on rituximab diagnosed with COVID-19 in July 2020 with persistent infection for over 245 days. Results: The patient received numerous treatment courses for persistent COVID-19 infection, including remdesivir, baricitinib, immunoglobulin and high doses of corticosteroids followed by a prolonged taper due to persistent respiratory symptoms and cryptogenic organizing pneumonia. Her clinical course was complicated by Pseudomonas aeruginosa sinusitis with secondary bacteremia, and cytomegalovirus (CMV) viremia and pneumonitis. SARS-CoV-2 positive RNA samples were extracted from two nasopharyngeal swabs and sequenced using targeted amplicon Next-Generation Sequencing which were analyzed for virus evolution over time. Viral sequencing indicated lineage B.1.585.3 SARS-CoV-2 accumulated Spike protein mutations associated with immune evasion and resistance to therapeutics. Upon slowly decreasing the patient's steroids, she had resolution of her symptoms and had a negative nasopharyngeal SARS-CoV-2 PCR and serum CMV PCR in March 2021. Conclusion: A patient with RA on B-cell depleting therapy developed persistent SARS-CoV-2 infection allowing for virus evolution and had numerous complications, including viral and bacterial co-infections with opportunistic pathogens. Despite intra-host evolution with a more immune evasive SARS-CoV-2 lineage, it was cleared after 245 days with reconstitution of the patient's immune system.
