Organising pneumonia due to inadequately cleared COVID-19 infection while on rituximab

Area of Science:

• Immunology
• Infectious Diseases
• Pulmonology

Background:

• Rheumatoid arthritis and organizing pneumonia patients on immunosuppressants like rituximab may have impaired viral clearance.
• Elderly patients with a history of smoking are at higher risk for severe respiratory illness.
• Reactivation or persistent infection of SARS-CoV-2 (the virus causing COVID-19) is a concern in immunocompromised individuals.

Observation:

• An elderly male patient with rheumatoid arthritis, treated with rituximab and tocilizumab, presented with worsening dyspnea and hypoxia.
• Initial SARS-CoV-2 testing was negative, but bronchoalveolar lavage confirmed COVID-19, with negative spike antibodies.
• The patient had a history of COVID-19 infection six months prior, suggesting a failure to clear the virus due to immunosuppression.

Findings:

• Persistent SARS-CoV-2 infection was diagnosed in an immunocompromised patient despite initial negative PCR tests.
• The patient's immunocompromised status, particularly due to rituximab therapy, was implicated in the inability to clear the prior COVID-19 infection.
• Bronchoalveolar lavage proved crucial in diagnosing persistent infection when standard PCR tests were negative.

Implications:

• This case underscores the importance of considering persistent viral infections in immunocompromised patients presenting with respiratory symptoms.
• Aggressive antiviral and anti-inflammatory treatment, including nirmatrelvir/ritonavir, remdesivir, and corticosteroids, can be effective in managing persistent COVID-19.
• Further research is needed to understand the long-term implications of persistent SARS-CoV-2 infection and optimize treatment strategies in immunocompromised populations.