COVID-19 pneumonia in a patient with granulomatosis with polyangiitis on rituximab: case-based review

Abstract

A 77-year-old man with past medical history of granulomatosis with polyangiitis (GPA) on rituximab and prednisone, presented to the hospital with worsening cough and shortness of breath. He had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by nasal swab polymerase chain reaction (PCR) while asymptomatic, 6 weeks earlier. He started with cough and shortness of breath 2 weeks after his initial positive test. After developing symptoms, he tested negative twice by nasal swab PCR, but the PCR of his bronchioloalveolar lavage was positive for SARS-CoV-2. He did not develop antibodies against coronavirus. Prednisone 15 mg daily was continued, and he received remdesivir, and convalescent plasma with quick recovery. We reviewed the literature to search for similar cases. Our case suggests that SARS-CoV-2 infection in patients on rituximab may have an atypical presentation and the diagnosis may be delayed due to negative PCR testing in the nasal swab. Patients may benefit from treatment with convalescent plasma.

Protracted severe COVID-19 pneumonia following rituximab treatment: caution needed

“…We identified 18 cases of patients with rheumatic diseases (6 RA, 8 ANCA vasculitis, 3 Systemic sclerosis and 1 polymyositis) treated with RTX who experienced an atypical, prolonged course [ 6 – 19 ]. By reviewing these cases we found that most had a similar protracted course with no evidence of cytokine storm (details for each case are presented in Table 1 ).…”

COVID-19 in patients with B cell immune deficiency

“…A case report analyzed a patient with malignant B cell lymphoma on chemotherapy who had active virus recovered over three months, with interval evolution of the viral strain during that time in that individual ( Kemp et al, 2021 ). In another case report, a patient receiving rituximab had initially asymptomatic infection, which progressed to symptomatic disease over several weeks in a delayed presentation ( Rodriguez-Pla et al, 2021 ). The lack of an effective immune response appears to prolong illness in many other B-cell depleting conditions as well ( Brown et al, 2021 ).…”

Concomitant presentation of eosinophilic or oncocytic mucoepidermoid carcinoma, immunoglobulin G4–related disease, and adult-onset asthma and periocular xanthogranuloma: Case report of 3 uncommon clinical entities

“…[ 13 ] The patient, however, declined rituximab therapy because she was concerned about prolonged immunosuppression during the coronavirus disease 2019 pandemic. [ 14 ] She was started instead on an oral glucocorticoid regimen (prednisone) and methotrexate, which have proved useful for treating both IgG4-RD and AAPOX. [ 2 , 15 ] Subsequently, she noted substantial improvement in her symptoms.…”