Atypical COVID-19 dynamics in a patient with Mantle Cell Lymphoma Exposed to Rituximab

Abstract

Patients with non-hodgkin lymphomas (NHL) represent a population of special interest during the current Coronavirus disease-19 (COVID-19) pandemics. NHLs are associated with disease- and treatment-related immunodeficiencies which may generate unusual COVID-19 dynamics and pose unique management challenges. We report the unusual clinical course of COVID-19 in a patient with mantle cell lymphoma (MCL) exposed to nine doses of Rituximab shortly before infection with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). He had a prolonged asymptomatic phase, with negative molecular and antibody testing for SARS-CoV-2, followed by a rapidly progressive evolution to severe COVID-19. Despite detection of viral RNA overlapped with first symptoms occurrence, anti-SARS-CoV-2 antibodies displayed an asynchronous pattern, with IgG first appearing two days after RNA positivity and IgM never being detected throughout the entire clinical course. While disease-associated immune derangements and/or previous treatments involving anti-CD20 antibodies might have contributed to COVID-19 dynamics in our patient, data suggests that antibody testings, without concurrent molecular assessment for SARS-CoV-2, may turn inadequate for monitoring of MCL patients, and in general NHL patients heavily exposed to anti-CD20 antibodies, during the current pandemics. Since these patients should not be denied or delayed effective treatments, we suggest that repeated molecular testing of nasopharyngeal swab should be implemented in these subjects despite a negative serology and absence of symptoms of SARS-CoV-2 infection. For the same reasons, a customized strategy needs to be developed for patients exposed to anti-CD20 antibodies, based on different features and mechanism of action of currently available SARS-CoV-2 vaccines.

Safety of administration of BNT162b2 mRNA (Pfizer‐BioNTech) COVID‐19 vaccine in youths and young adults with a history of acute lymphoblastic leukemia and allergy to PEG‐asparaginase

“…The COVID‐19 virus has been responsible for a global health crisis with, to date, over 150 million cases and 3.7 million deaths worldwide 1,2 . Those with a malignant diagnosis are at risk of poor outcome following COVID‐19 infection 3–7 …”

Recovery from severe persistent COVID-19 without evidence of an anti-SARS-CoV-2 antibody response in a man with mantle cell lymphoma treated with rituximab

“…rituximab therapy has been reported [7], poor outcomes have also been reported in MCL patients who develop COVID-19 while on rituximab therapy [8,9]. Despite the lack of antibody-producing B cells, our patient had severe symptoms and was considered to have a very poor prognosis.…”

COVID-19 Pneumonia in Vaccinated Population: A Six Clinical and Radiological Case Series

“…It has been also reported that the use of the anti-CD20 antibody rituximab, with or without chemotherapy, is typically associated with impaired humoral responses to influenza vaccines [ 38 ]. Similar cases are emerging with SARS-CoV-2 vaccines [ 39 , 40 , 41 , 42 , 43 ]. Rituximab is associated with B cell 141 depletion for up to 78 weeks following use.…”

“…Rituximab is associated with B cell 141 depletion for up to 78 weeks following use. On the other hand, patients with non-Hodgkin lymphomas (NHLs) are associated with disease-related immunodeficiency, which may render these patients especially susceptible to SARS-CoV-2 infection [ 39 ]. Immunocompromised patients likely acquire different clades of SARS-CoV-2 45 infection.…”