Case Report: Cyclophosphamide in COVID-19 – when an absolute contraindication is an absolute necessity

Abstract

Background: Despite many studies on COVID-19, our knowledge of it remains incomplete. In some cases, treating SARS-CoV-2 infection concomitant with other diseases can be particularly challenging, as finding an appropriate treatment may involve some risks. Case presentation: A 34-year-old SARS-CoV-2 positive patient admitted due to fever, dyspnoea, haemoptysis and pneumonia, developed alveolar haemorrhage and acute kidney injury. Due to his severe state, abnormalities in laboratory tests and rapidly progressing loss of kidney function, kidney biopsy, as well as antibody panel were carried out, in which perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) were found with a high titer (>200; N: <1:20). The results of kidney biopsy, combined with clinical manifestation and laboratory findings prompted the diagnosis of rapidly progressing glomerulonephritis (RPGN) in the course of p-ANCA vasculitis. Initial treatment consisted of heamodialyses, remdesivir, plasmaphereses, intravenous immunoglobulins, antibiotics, corticosteroids and fraxiparine. Once the haemorrhage had subsided, kidney function had been partially retrieved and heamodialyses had no longer been necessary, cyclophosphamide treatment was initiated, despite being contraindicated in COVID-19 according to its summary of product characteristics. Immunotherapy is still continued. The patient has already received a total of 2.4g of cyclophosphamide (4 cycles of 600mg each every three weeks). Pulmonary and radiological regression, as well as improvement of renal parameters have been achieved. Conclusions: We suspect that cyclophosphamide, the drug of choice in p-ANCA vasculitis, could be a potential factor providing regression of the radiological changes in the lungs and it could have prevented the patient from developing acute respiratory distress syndrome. COVID-19 diagnosis should not exclude searching for other diseases which can have a similar course. When treating a patient in a life-threatening condition, a departure from trying to find the perfect timing of cyclophosphamide delivery should be considered, as delaying it could cause potentially greater harm.

New‐onset ANCA‐associated vasculitis presenting with neuropathy after COVID‐19 infection: A case report and literature review

“…One of them is molecular mimicry, leading to the immune system falsely attacking its self‐tissues when a viral protein is analogous to a protein in the body 13 . Another mechanism is bystander activation, in which the immune system responds to the virus and inadvertently attacks nearby healthy tissue 14 . A third mechanism is epitope spreading, where the immune system initially targets the virus but then begins attacking other proteins in the body that are not directly related to the virus 7 .…”

“… 13 Another mechanism is bystander activation, in which the immune system responds to the virus and inadvertently attacks nearby healthy tissue. 14 A third mechanism is epitope spreading, where the immune system initially targets the virus but then begins attacking other proteins in the body that are not directly related to the virus. 7 SARS‐CoV‐2 can also induce an immune response by elevating interleukin‐6 (IL‐6).…”

What does immunology say to rheumatologists that it does not say to others?

“…Many controversies exist as far as the treatment of the patients is concerned. Immunosuppressive treatment although contraindicated in the course of infection may be a risky option but in some cases result in remission attainment [8].…”