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

doi:10.1016/j.heliyon.2023.e23699

Successful treatment of SARS-CoV-2 in an immunocompromised patient with persistent infection for 245 days: A case report

Heliyon. 2023 Dec 14;10(1):e23699. doi: 10.1016/j.heliyon.2023.e23699. eCollection 2024 Jan 15.

Authors

Victoria Overbeck¹, Bradford P Taylor², Jacquelyn Turcinovic^{3

4

5}, Xueting Qiu², Beau Schaeffer², Scott Seitz^{3

4}, Scott R Curry⁶, William P Hanage², John H Connor^{3

4

5}, Krutika Kuppalli⁶

Affiliations

¹ Departments of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, MA, USA.
² Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
³ Department of Microbiology, Boston University School of Medicine, Boston, MA, USA.
⁴ National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, USA.
⁵ Program in Bioinformatics, Boston University, Boston, MA, USA.
⁶ Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.

Abstract

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.

Keywords: COVID-19; Immunocompromised; Persistent infection; Variant of concern; Virus evolution.

Publication types

Case Reports