Febrile neutropenia due to COVID-19 in an immunocompetent patient

The Effectiveness and Safety of Remdesivir Use in COVID-19 Patients with Neutropenia: A Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic poses severe risks for immunocompromised patients, especially those with neutropenia due to chemotherapy. This study evaluates the safety and effectiveness of remdesivir use in COVID-19 patients with neutropenia.

METHODS

This retrospective study used the Chang Gung Research Database (CGRD) and extracted data from 98,763 patients with COVID-19 diagnosed between April 2021 and September 2022. The patients were divided into groups based on their remdesivir use and the presence of neutropenia. The adverse effects of remdesivir and their outcomes were analyzed after propensity score matching.

RESULTS

We compared common adverse effects of remdesivir in neutropenic patients before and after a 5-day regimen. A slight decrease in heart rate was observed but lacked clinical significance. There were no significant differences observed in hemoglobin, liver function tests, and blood glucose levels. After propensity score matching of COVID-19 patients with neutropenia according to gender, age, dexamethasone use, oxygen use, MASCC score, and WHO ordinal scale, no significant differences were found in length of stay, intubation rate, or ICU admission rate between the matched patients.

CONCLUSIONS

Our study found remdesivir to be safe for COVID-19 patients with neutropenia, with no common adverse reactions observed. However, its effectiveness for these patients remains uncertain.

Isolated Severe Neutropenia in Adults, Evaluation of Underlying Causes and Outcomes, Real-World Data Collected over a 5-Year Period in a Tertiary Referral Hospital

Background and Objectives: In clinical practice, neutropenia is frequently accompanied by other cytopenia; isolated non-chemotherapy-induced severe neutropenia is less frequent and its differential diagnosis can be challenging. In this real-world study with data collected over a 5-year period in a tertiary referral hospital, we primarily sought to identify underlying causes of isolated severe neutropenia (<0.5 × 109/L). Secondly, we aimed to analyze its management and outcomes. Materials and Methods: From 444,926 screened patients, after exclusion of patients with chemotherapy, radiotherapy, hematological neoplasms, additional cytopenia, and benign ethnic neutropenia, we identified and analyzed data from 70 patients (0.015%) with isolated severe neutropenia. We thus confirmed that the occurrence of isolated severe neutropenia is a rare event, even in a tertiary hospital. Results: The median age at diagnosis was 34 years (range 1-81) and 65% were female. Acute neutropenia was more frequently observed (n = 46/70, 65.7%); the main underlying causes in this group were drugs (n = 36/46, 78%) followed by infections (n = 10/46, 21.7%). We identified 24 (34.3%) patients with chronic neutropenia. The majority of them (n = 12/24, 50%) had an idiopathic form (CIN), 8/24 (33%) were autoimmune (AIN), and 4/24 (17%) were congenital. Conclusions: This study demonstrates the rarity and heterogeneity of isolated severe neutropenia and the steps to consider in its diagnostic work-up and management. Epidemiological characteristics, diagnostic work-up, and management including hospitalizations are described. Due to the high frequency of metamizole-induced neutropenia observed in this study, we want to raise awareness about its use, since this complication generates frequent hospitalizations even in young, otherwise healthy patients. Furthermore, recurrent infections in chronic forms of idiopathic neutropenia were quite common, suggesting a difference in phenotypes and need for therapy consideration depending on the clinical course.

Coexistence of Pancytopenia and Myositis After Developing COVID-19

COVID-19 causes not only acute but also subacute medical conditions during the clinical course. COVID-19 causes severe inflammatory conditions; therefore, patients may develop long-term complications. Among patients with acute COVID-19, some patients can experience persistent symptoms, such as fatigue, joint pain, and smell and taste abnormalities, known as the long COVID-19 syndrome. The symptoms can be severe and require continuous medical care. Patients with severe clinical courses of COVID-19 may have critical symptoms again after the cure of the acute infections, especially among older patients. We encountered a case of neutropenia and myositis one month after contracting COVID-19. An 89-year-old man presented to our hospital with acute-onset systemic muscle pain and difficulty in movement and speaking. The patient had neutropenia and myositis with an extremely high level of immunoglobulin G caused by COVID-19. A granulocyte colony-stimulating factor could be effective for treating neutropenia. Besides, prednisolone was effective for treating myositis. In community hospitals, after developing COVID-19, appropriate history taking and physical examination should be performed in older patients with ambiguous symptoms, as they might have critical medical conditions such as neutropenia and myositis. The appropriate diagnosis and treatments of older patients with the complications of COVID-19 should be performed.

Ethnicity-Specific Features of COVID-19 Among Arabs, Africans, South Asians, East Asians, and Caucasians in the United Arab Emirates

Background

Dubai (United Arab Emirates; UAE) has a multi-national population which makes it exceptionally interesting study sample because of its unique demographic factors.

Objective

To stratify the risk factors for the multinational society of the UAE.

Methods

A retrospective chart review of 560 patients sequentially admitted to inpatient care with laboratory confirmed COVID-19 was conducted. We studied patients’ demographics, clinical features, laboratory results, disease severity, and outcomes. The parameters were compared across different ethnic groups using tree-based estimators to rank the ethnicity-specific disease features. We trained ML classification algorithms to build a model of ethnic specificity of COVID-19 based on clinical presentation and laboratory findings on admission.

Results

Out of 560 patients, 43.6% were South Asians, 26.4% Middle Easterns, 16.8% East Asians, 10.7% Caucasians, and 2.5% are under others. UAE nationals represented half of the Middle Eastern patients, and 13% of the entire cohort. Hypertension was the most common comorbidity in COVID-19 patients. Subjective complaint of fever and cough were the chief presenting symptoms. Two-thirds of the patients had either a mild disease or were asymptomatic. Only 20% of the entire cohort needed oxygen therapy, and 12% needed ICU admission. Forty patients (~7%) needed invasive ventilation and fifteen patients died (2.7%). We observed differences in disease severity among different ethnic groups. Caucasian or East-Asian COVID-19 patients tended to have a more severe disease despite a lower risk profile. In contrast to this, Middle Eastern COVID-19 patients had a higher risk factor profile, but they did not differ markedly in disease severity from the other ethnic groups. There was no noticeable difference between the Middle Eastern subethnicities—Arabs and Africans—in disease severity (p = 0.81). However, there were disparities in the SOFA score, D-dimer (p = 0.015), fibrinogen (p = 0.007), and background diseases (hypertension, p = 0.003; diabetes and smoking, p = 0.045) between the subethnicities.

Conclusion

We observed variations in disease severity among different ethnic groups. The high accuracy (average AUC = 0.9586) of the ethnicity classification model based on the laboratory and clinical findings suggests the presence of ethnic-specific disease features. Larger studies are needed to explore the role of ethnicity in COVID-19 disease features.

COVID 19 and febrile neutropenia: Case report and systematic review

Objectives

In pandemic conditions, patients with febrile neutropenia are also at risk of COVID-19. Aim of this systematic review is to evaluate COVID-19 cases presented with febrile neutropenia and provide information regarding incidence, clinical course and prognosis.

Methods

We systematically searched on COVID-19 and febrile neutropenia cases in PubMed, SCOPUS and Web of Science.

Results

A total of 19 febrile neutropenic patients were analyzed. A male predominance was noted. Eleven cases had hematological malignancies. Fourteen of the cases were previously received chemotherapy. Five patients had severe neutropenia: 3 had hematologic cancer and none died. 17 (89.5%) cases have pulmonary involvement and seven of them had severe disease with acute respiratory distress syndrome (ARDS). Three cases with ARDS were died. 12 of them received G-CSF for treatment. Five cases were developed respiratory failure after G-CSF use. Overall mortality was 15.8%, while death was not observed in patients without malignancy and solid organ tumors, the mortality rate was 27% in cases with hematological malignancies.

Conclusion

In ongoing pandemic, febrile neutropenic patients should be precisely evaluated for COVID-19 disease. It should be remembered that there may not be typical signs and symptoms and laboratory findings of COVID-19 disease because of the immunosuppression.

Tree Shrew Is a Suitable Animal Model for the Study of Epstein Barr Virus

Epstein-Barr virus (EBV) is a human herpesvirus that latently infects approximately 95% of adults and is associated with a spectrum of human diseases including Infectious Mononucleosis and a variety of malignancies. However, understanding the pathogenesis, vaccines and antiviral drugs for EBV-associated disease has been hampered by the lack of suitable animal models. Tree shrew is a novel laboratory animal with a close phylogenetic relationship to primates, which is a critical advantage for many animal models for human disease, especially viral infections. Herein, we first identified the key residues in the CR2 receptor that bind the gp350 protein and facilitate viral entry. We found that tree shrew shares 100% sequence identity with humans in these residues, which is much higher than rabbits (50%) and rats (25%). In vitro analysis showed that B lymphocytes of tree shrews are susceptible to EBV infection and replication, as well as EBV-enhanced cell proliferation. Moreover, results of in vivo experiments show that EBV infection in tree shrews resembles EBV infection in humans. The infected animals exhibited transient fever and loss of weight accompanied by neutropenia and high viremia levels during the acute phase of the viral infection. Thereafter, tree shrews acted as asymptomatic carriers of the virus in most cases that EBV-related protein could be detected in blood and tissues. However, a resurgence of EBV infection occurred at 49 dpi. Nanopore transcriptomic sequencing of peripheral blood in EBV-infected animals revealed the dynamic changes in biological processes occurring during EBV primary infection. Importantly, we find that neutrophil function was impaired in tree shrew model as well as human Infectious Mononucleosis datasets (GSE85599 and GSE45918). In addition, retrospective case reviews suggested that neutropenia may play an important role in EBV escaping host innate immune response, leading to long-term latent infection. Our findings demonstrated that tree shrew is a suitable animal model to evaluate the mechanisms of EBV infection, and for developing vaccines and therapeutic drugs against EBV.

Self-limiting severe neutropenia in a patient with COVID-19

Neutropenia is a rare haematological complication of COVID-19 infection in immunocompetent patients. There is sparse literature on neutropenia in patients with COVID-19, except a few case reports. We encountered a similar case in an intensive care unit that developed severe neutropenia on day 24 of illness. Neutropenia resolved spontaneously on 4th day of its appearance. The patient was isolated and kept under close observation, antibiotics were upgraded and strict asepsis was maintained. Thus, we observed in a patient with no comorbidities and uncomplicated neutropenia that strict measures to prevent infection may suffice and the undue risk of hematopoietic therapy can be avoided. An expert opinion should always be sought in such cases as the presence of complications may require an aggressive approach.