COVID-19 infection in a patient with multiple sclerosis treated with fingolimod

Abstract

In December 2019, a novel coronavirus causing an infectious respiratory disease was identified, which since then has developed into a pandemic with higher rates of mortality in older individuals and those with underlying medical conditions. 1 Multiple sclerosis (MS) is an immune-mediated neurologic disease which requires long-term treatment with immunotherapies that have been shown to increase the risk of infections. 2 As a result, there is significant anxiety among patients and neurologists during the pandemic regarding the infection outcome in this patient population. We present a patient with MS treated with fingolimod who was diagnosed with COVID-19 and had a favorable outcome. Case presentationA 42-year-old woman who was diagnosed with relapsing-remitting MS according to the McDonald criteria in 2001 and had been treated with methotrexate (2 years; discontinued because of elevated liver enzymes), interferon beta 1-a (13 years; discontinued because of disease activity), and recently on fingolimod (since 4 years ago) presented with muscle aches, gait difficulty, sensory disturbances, and weakness on the right side. Her other comorbidities included major depression disorder, hypothyroidism, recurrent urinary tract infection, and histories of pulmonary embolism on direct oral anticoagulation and myasthenia gravis (diagnosed 5 years before MS and status after thymectomy). At her most recent follow-up in September 2019, her expanded disability status scale (EDSS) score was 1.0 for a positive Babinski sign on the right side. MRI was notable for moderate disease burden in the brain and the presence of 2 right-sided cervical cord lesions. Her lymphocyte count at this visit was 842.4/μL.On March 1, 2020, she started experiencing the symptoms that gradually worsened over the next few days. She sought medical attention on March 5 and was seen at the outpatient MS clinic. Neurologic examination revealed decreased sensation, reduced muscle strength (4/5), and brisk reflexes on the right and right positive Babinski sign (EDSS of 4). These findings were consistent with new relapse or recrudescence of old symptoms (pseudoexacerbation). She was then admitted for a relapse workup and treatment on the same day. On arrival, she was afebrile with vital signs within normal limits. Initial laboratory investigations were notable for C-reactive protein of 76 mg/L and erythrocyte sedimentation rate of 46 mm, raising suspicious for an underlying infectious etiology. There was also a decrease in absolute lymphocyte count (601.6/μL), which was attributed to fingolimod. Methylprednisolone IV 1,000 mg/d was initiated for 3 days for the treatment of a possible relapse. As part of the infectious workup, chest X-ray showed a ground glass opacity ( figure, A), which raised a possibility of community-acquired pneumonia for which she was started on azithromycin 500 mg daily because she is allergic to fluoroquinolones. On March 7, she developed dry cough, dyspnea, and fever (38.7°C). She also had tachycardia (122), increased respiratory rate (30...

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A case series and literature review of multiple sclerosis and COVID-19: Clinical characteristics, outcomes and a brief review of immunotherapies

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