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Nasrullah A, Shakir H, Khan E, Bilal MI, Sheikh AB, Malik K, Cheema T. COVID-19-related Pneumonitis in Immunocompromised Patients: Reviewing Clinical Features and Management Approaches. J Community Hosp Intern Med Perspect 2024; 14:63-72. [PMID: 39399191 PMCID: PMC11466343 DOI: 10.55729/2000-9666.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 07/01/2024] [Accepted: 07/17/2024] [Indexed: 10/15/2024] Open
Abstract
In this case series, we explore persistent SARS-CoV-2 infection and its resultant pneumonitis within a cohort of immunocompromised patients. We elucidate the complex interplay between immunosuppression and COVID-19 by examining four patients who experienced prolonged viral shedding and recurrent respiratory failure due to their compromised immune systems. This series elucidates the clinical presentation, diagnostic challenges, and therapeutic strategies. We also summarize existing literature regarding persistent SARS-CoV-2 infection in immunocompromised individuals. Our findings support the use of a tailored treatment approach using a proposed diagnostic and management algorithm to standardize care and optimize outcomes.
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Affiliation(s)
- Adeel Nasrullah
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | - Hassan Shakir
- The Wright Center of Graduate Medical Education, Scranton, PA, 18505, USA
| | - Eiraj Khan
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | - Muhammad I Bilal
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | - Abu B Sheikh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87106, USA
| | - Khalid Malik
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | - Tariq Cheema
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, 15212, USA
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Yamashita M, Higo H, Fujii N, Matsumoto C, Makimoto G, Ninomiya K, Fujii M, Rai K, Ichihara E, Ohashi K, Hotta K, Tabata M, Maeda Y, Miyahara N. Protracted coronavirus disease 2019 after chimeric antigen receptor-T cell therapy successfully treated with sequential multidrug therapy. Respir Med Case Rep 2024; 51:102104. [PMID: 39286407 PMCID: PMC11404050 DOI: 10.1016/j.rmcr.2024.102104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 08/20/2024] [Accepted: 08/29/2024] [Indexed: 09/19/2024] Open
Abstract
A 56-year-old woman who received CD19 chimeric antigen receptor-T cell therapy for refractory diffuse large B-cell lymphoma developed severe coronavirus disease 2019 (COVID-19) and was treated with nirmatrelvir/ritonavir in April 2022. However, she experienced persistent fatigue and cough and fever in June. Computed tomography revealed bilateral ground-glass opacities (GGO), and the patient was treated with corticosteroids for organizing pneumonia after COVID-19. Partial improvement was observed, but new GGO appeared despite corticosteroid therapy. Genome analysis of severe acute respiratory syndrome coronavirus 2 detected Omicron variant BA.1.1.2, which was prevalent at the time of initial infection. The patient was diagnosed with protracted COVID-19 and was treated with remdesivir, molnupiravir, nirmatrelvir/ritonavir, and tixagevimab/cilgavimab. These treatments appeared to contribute to the improvement of protracted COVID-19.
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Affiliation(s)
- Masahiro Yamashita
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
| | - Hisao Higo
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
| | - Nobuharu Fujii
- Department of Hematology and Oncology, Okayama University Hospital, Japan
| | - Chiaki Matsumoto
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
| | - Go Makimoto
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
| | - Kiichiro Ninomiya
- Center for Comprehensive Genomic Medicine, Okayama University Hospital, Japan
| | - Masanori Fujii
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
| | - Kammei Rai
- Center for Innovative Clinical Medicine, Okayama University Hospital, Japan
| | - Eiki Ichihara
- Center for Clinical Oncology, Okayama University Hospital, Japan
| | - Kadoaki Ohashi
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
| | - Katsuyuki Hotta
- Center for Innovative Clinical Medicine, Okayama University Hospital, Japan
| | - Masahiro Tabata
- Center for Clinical Oncology, Okayama University Hospital, Japan
| | - Yoshinobu Maeda
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Nobuaki Miyahara
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Japan
- Department of Medical Technology, Okayama University Academic Field of Health Sciences, Japan
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Kinsella PM, Moso MA, Morrissey CO, Dendle C, Guy S, Bond K, Sasadeusz J, Slavin MA. Antiviral therapies for the management of persistent coronavirus disease 2019 in immunocompromised hosts: A narrative review. Transpl Infect Dis 2024; 26:e14301. [PMID: 38809102 DOI: 10.1111/tid.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/11/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
Antiviral agents with activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have played a critical role in disease management; however, little is known regarding the efficacy of these medications in the treatment of SARS-CoV-2 infection in immunocompromised patients, particularly in the management of persistent SARS-CoV-2 positivity. This narrative review discusses the management of persistent coronavirus disease 2019 in immunocompromised hosts, with a focus on antiviral therapies. We identified 84 cases from the literature describing a variety of approaches, including prolonged antiviral therapy (n = 11), combination antivirals (n = 13), and mixed therapy with antiviral and antibody treatments (n = 60). A high proportion had an underlying haematologic malignancy (n = 67, 80%), and were in receipt of anti-CD20 agents (n = 51, 60%). Success was reported in 70 cases (83%) which varied according to the therapy type. Combination therapies with antivirals may be an effective approach for individuals with persistent SARS-CoV-2 positivity, particularly those that incorporate treatments aimed at increasing neutralizing antibody levels. Any novel approaches taken to this difficult management dilemma should be mindful of the emergence of antiviral resistance.
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Affiliation(s)
- Paul M Kinsella
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Michael A Moso
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | | | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Stephen Guy
- Department of Infectious Diseases, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Katherine Bond
- Department of Microbiology, Royal Melbourne Hospital, Melbourne, Australia
- Victorian Infectious Diseases Reference Laboratory (VIDRL) at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Microbiology and Immunology, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Joseph Sasadeusz
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Götz V, Mathé P, Agarwal P, Hornuss D, Pfau S, Panning M, Prager E, Voll RE, Engelhardt M, Frye BC, Bamberg F, Fuchs J, Müller M, Wagner D, Rieg S. Clinical phenotype and outcome of persistent SARS-CoV-2 replication in immunocompromised hosts: a retrospective observational study in the Omicron era. Infection 2024; 52:923-933. [PMID: 38095753 PMCID: PMC11142974 DOI: 10.1007/s15010-023-02138-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/10/2023] [Indexed: 06/02/2024]
Abstract
PURPOSE This study aims to describe clinical, virological and radiological characteristics as well as treatment strategies and outcomes of immunocompromised patients with persistent SARS-CoV-2 replication. METHODS We performed a retrospective cohort study of immunocompromised patients at the University Medical Center Freiburg between 01/2022 and 05/2023. Patients with substantial immunosuppression and persistent SARS-CoV-2 detection (Ct-value < 30 after 14 days) were included. RESULTS 36 patients in our cohort reported mainly fever, dyspnoea or continuous cough. Viral load was significantly higher in concurrent samples taken from the lower respiratory tract (Ct-value = 26) than from the upper respiratory tract (Ct-value = 34). Time of detectable viral RNA after start of antiviral treatment was shorter in patients receiving two antivirals (median 15 days vs. 31 days with one antiviral agent). Short-course antiviral therapy (≤ 5 days) was less efficient in reduction of symptoms and viral load than prolonged therapy > 10 days. In 30% (8/27) of patients with repeated CT scans, we found the emergence of chronic pulmonary changes, which were more frequently in patients with B cell depletion (37%, 7/19) compared to patients with organ transplantation (12%, 2/17). CONCLUSION Ongoing SARS-CoV-2 replication in the lower respiratory tract is a relevant differential diagnosis in patients with severe immunosuppression and continuous cough, fever or dyspnoea even if nasopharyngeal swabs test negative for SARS-CoV-2. Especially in B cell-depleted patients, this may lead to inflammatory or fibrotic-like pulmonary changes, which are partially reversible after inhibition of viral replication. Antiviral therapy seems to be most effective in combination and over a prolonged period of time of > 10 days. TRIAL REGISTRATION NUMBER DRKS 00027299.
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Affiliation(s)
- Veronika Götz
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Philipp Mathé
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Prerana Agarwal
- Faculty of Medicine, Department of Radiology, Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Daniel Hornuss
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Stefanie Pfau
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Marcus Panning
- Faculty of Medicine, Institute of Virology, Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Eric Prager
- Faculty of Medicine, Department of Nephrology, University Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Reinhard E Voll
- Faculty of Medicine, Department of Rheumatology and Clinical Immunology, Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Monika Engelhardt
- Faculty of Medicine, Department of Internal Medicine I, Hematology, Oncology and Stem Cell Transplantation, University Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Björn C Frye
- Faculty of Medicine, Department of Pneumology, Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Fabian Bamberg
- Faculty of Medicine, Department of Radiology, Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Jonas Fuchs
- Faculty of Medicine, Institute of Virology, Medical Center, University of Freiburg, 79106, Freiburg, Germany
| | - Matthias Müller
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Infection Medicine, Medical Service Centre Clotten, 79106, Freiburg, Germany
| | - Dirk Wagner
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Siegbert Rieg
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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Hayashino K, Seike K, Fujiwara K, Kondo K, Matsubara C, Terao T, Kitamura W, Kamoi C, Fujiwara H, Asada N, Nishimori H, Ennishi D, Fujii K, Fujii N, Matsuoka KI, Maeda Y. Chimeric antigen receptor T-cell therapy after COVID-19 in refractory high-grade B-cell lymphoma. Int J Hematol 2024; 119:459-464. [PMID: 38349446 PMCID: PMC10960909 DOI: 10.1007/s12185-024-03711-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 03/24/2024]
Abstract
Although chimeric antigen receptor T-cell (CAR-T) therapies have dramatically improved the outcomes of relapsed/refractory B-cell malignancies, recipients suffer from severe humoral immunodeficiencies. Furthermore, patients with coronavirus disease 2019 (COVID-19) have a poor prognosis, as noted in several case reports of recipients who had COVID-19 before the infusion. We report the case of a 70-year-old woman who developed COVID-19 immediately before CAR-T therapy for high-grade B-cell lymphoma. She received Tixagevimab-Cilgavimab chemotherapy and radiation therapy but never achieved remission. She was transferred to our hospital for CAR-T therapy, but developed COVID-19. Her symptoms were mild and she was treated with long-term molnupiravir. On day 28 post-infection, lymphodepleting chemotherapy was restarted after a negative polymerase chain reaction (PCR) test was confirmed. The patient did not experience recurrence of COVID-19 symptoms or severe cytokine release syndrome. Based on the analysis and comparison of the previous reports with this case, we believe that CAR-T therapy should be postponed until a negative PCR test is confirmed. In addition, Tixagevimab-Cilgavimab and long term direct-acting antiviral agent treatment can be effective prophylaxis for severe COVID-19 and shortening the duration of infection.
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Affiliation(s)
- Kenta Hayashino
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Keisuke Seike
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan.
| | - Kanako Fujiwara
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Kaho Kondo
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Chisato Matsubara
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Toshiki Terao
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Wataru Kitamura
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Chihiro Kamoi
- Division of Blood Transfusion, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Hideaki Fujiwara
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Noboru Asada
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Daisuke Ennishi
- Center for Comprehensive Genomic Medicine, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Keiko Fujii
- Division of Clinical Laboratory, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Nobuharu Fujii
- Division of Blood Transfusion, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata, Okayama-shi, Okayama, Japan
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Meyerowitz EA, Scott J, Richterman A, Male V, Cevik M. Clinical course and management of COVID-19 in the era of widespread population immunity. Nat Rev Microbiol 2024; 22:75-88. [PMID: 38114838 DOI: 10.1038/s41579-023-01001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/21/2023]
Abstract
The clinical implications of COVID-19 have changed since SARS-CoV-2 first emerged in humans. The current high levels of population immunity, due to prior infection and/or vaccination, have been associated with a vastly decreased overall risk of severe disease. Some people, particularly those with immunocompromising conditions, remain at risk for severe outcomes. Through the course of the pandemic, variants with somewhat different symptom profiles from the original SARS-CoV-2 virus have emerged. The management of COVID-19 has also changed since 2020, with the increasing availability of evidence-based treatments in two main classes: antivirals and immunomodulators. Selecting the appropriate treatment(s) for patients with COVID-19 requires a deep understanding of the evidence and an awareness of the limitations of applying data that have been largely based on immune-naive populations to patients today who most likely have vaccine-derived and/or infection-derived immunity. In this Review, we provide a summary of the clinical manifestations and approaches to caring for adult patients with COVID-19 in the era of vaccine availability and the dominance of the Omicron subvariants, with a focus on the management of COVID-19 in different patient groups, including immunocompromised, pregnant, vaccinated and unvaccinated patients.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
| | - Jake Scott
- Division of Infectious Diseases and Geographic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Aaron Richterman
- Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Male
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Muge Cevik
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK.
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