[Migratory pulmonary ground glass opacities caused by SARS-CoV-2 infection in a patient on B-cell depletion therapy]

Zhonghua Jie He He Hu Xi Za Zhi. 2023 Dec 12;46(12):1233-1239. doi: 10.3760/cma.j.cn112147-20230809-00061.
[Article in Chinese]

Abstract

In immunosuppressed individuals, the manifestation of viral pneumonia due to SARS-CoV-2 infection differs from that in healthy individuals. We reported a unique case of a 58-year-old male patient with B-cell depletion following treatment with the anti-CD20 monoclonal antibody. He presented to the Department of Pulmonary and Critical Care Medicine with complaints of intermittent fever and cough for three months, aggravated by shortness of breath for one month. He was previously diagnosed with stage IVA follicular lymphoma in April 2022 and underwent chemotherapy with Obinutuzumab (anti-CD20 monoclonal antibody). His last treatment was on November 3, 2022. On December 20, 2022, after contact with a SARS-CoV-2-infected person, he exhibited symptoms of fever peaking at 39.0 ℃, cough, and sputum production. A positive SARS-CoV-2 nucleic acid result was confirmed from a pharyngeal swab. Nine days later (December 29, 2022), the patient still had a fever. Chest CT showed multiple small pieces of ground glass opacities (GGOs) in both lower lungs. The diagnosis of viral pneumonia due to SARS-CoV-2 infection was confirmed. After five days of treatment with nirmatrelvir/ritonavir (Paxlovid) and intravenous dexamethasone (5 mg/d), his fever subsided. However, a subsequent chest CT on January 9, 2023 showed partial resorption of multiple GGOs in both lungs, accompanied by novel focal lesions. The patient developed a fever again on January 29, 2023, after which he had recurrent symptoms of fever, cough, and sputum, with intermittent short courses of antibiotics and dexamethasone, which never completely resolved. Multiple chest CTs during this period showed recurrent GGOs and consolidations in both lungs, demonstrating a migratory pattern. The patient was admitted to our hospital on March 7, 2023, with a peripheral blood test suggesting lymphocytopenia, a CD19+B lymphocyte count of zero, and negative IgG and IgM for SARS-CoV-2. A bronchoscopy and bronchoalveolar lavage fluid (BALF) analysis indicated a significantly elevated lymphocyte percentage and the presence of SARS-CoV-2 nucleic acid. Given the three-month history of chronic fever and respiratory symptoms, changing bilateral pulmonary infiltrates, and lack of SARS-CoV-2 humoral immunity, a diagnosis of persistent SARS-CoV-2 infection was considered. Subsequent treatment with Paxlovid for 15 days resulted in the resolution of all symptoms. A follow-up chest CT one month later showed almost complete normalization.

免疫抑制宿主新型冠状病毒(SARS-CoV-2)感染所致肺炎表现较健康人有所不同。本文报道一例既往滤泡性淋巴瘤经CD20单抗治疗后B细胞清除患者,自2022年12月感染SARS-CoV-2后出现反复发热、咳嗽、咳痰伴双肺多发游走性磨玻璃影,在2023年3月诊断为SARS-CoV-2感染致肺炎,给予奈玛特韦/利托那韦单药治疗15 d后症状缓解,双肺多发磨玻璃影吸收,且未反复。综合考虑患者病情可能为SARS-CoV-2“持续”或“迁延”感染导致。.

Publication types

  • Case Reports
  • English Abstract

MeSH terms

  • Antibodies, Monoclonal
  • Antineoplastic Agents*
  • COVID-19*
  • Cough / etiology
  • Dexamethasone
  • Fever
  • Humans
  • Lung / diagnostic imaging
  • Male
  • Middle Aged
  • Nucleic Acids*
  • Pneumonia, Viral* / complications
  • SARS-CoV-2

Substances

  • nirmatrelvir and ritonavir drug combination
  • Antineoplastic Agents
  • Antibodies, Monoclonal
  • Nucleic Acids
  • Dexamethasone