key: cord-0853068-kfep2cj5
authors: Bellmann‐Weiler, Rosa; Burkert, Francesco; Schwaiger, Theresa; Schmidt, Stephan; Ludescher, Christof; Oexle, Horst; Wolf, Dominik; Weiss, Günter
title: Janus faced course of COVID‐19 infection in patients with hematological malignancies
date: 2020-06-17
journal: Eur J Haematol
DOI: 10.1111/ejh.13470
sha: 2ed31e6352749884a56d32b58ccf3f4b2039a839
doc_id: 853068
cord_uid: kfep2cj5

The COVID‐19 pandemic affects most countries of the world resulting in significant morbidity and mortality from this infection with SARS‐CoV2 (1). It was reported that among others specifically patients with cancer (including patients with hematological malignancies) are at a higher risk for severe and fatal infection (2). Here, we report three consecutive patients with underlying hematologic malignancies and co‐morbidities who were admitted to the infectious diseases ward at our department because of SARS‐CoV2 infection.

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The COVID-19 pandemic affects most countries of the world resulting in significant morbidity and mortality from this infection with SARS-CoV2 (1) . It was reported that among others specifically patients with cancer (including patients with hematological malignancies) are at a higher risk for severe and fatal infection (2) . Here, we report three consecutive patients with underlying hematologic malignancies and co-morbidities who were admitted to the infectious diseases ward at our department because of SARS-CoV2 infection. Patient 1 reported weakness and weight loss already for several months, in his history he underwent surgery for colonic cancer followed by chemotherapy 23 years ago. He also suffered from diabetes, hypertension, obesity (BMI 26.8 kg/m²) and coronary heart disease, four additional risk factors for severe SARS-CoV2 infection (3) . Five days prior to diagnosis of the infection the patient developed fever and dyspnea. On admission he had a temperature of 38.5°C, cough and reported extreme weakness. Though not sensing dyspnea, his blood oxygenation was reduced with peripheral oxygen saturation of 86% and a pO2 of 58 mmHg.

Leucocyte and lymphocyte counts were reduced but in addition the differential blood counts revealed 30% of blasts, which were suggestive for acute myeloid leukemia (AML). Bone marrow aspiration confirmed diagnosis of AML NOS according to WHO with a DNMT3A mutation.

Continuous oxygen supplementation (6 L/min) was necessary to maintain a peripheral oxygen saturation >90% and alertness of the patient. Accordingly, crackling breath sounds were present over both sides of the lung which was in accordance with the finding of infiltrations in the chest X-ray. Under continuous inhalation with physiologic salt solution and oxygen supply, physiotherapy and medication with hydroxychloroquine, azithromycin and low dose prednisone from days 9-14 the patient slowly but gradually improved over a period of one week with stepwise reduction of oxygen needs to 2 l/min after 10 days. Oropharyngeal swabs taken on days 9 and 12 revealed SARS-CoV2 clearance with negative PCR results and the patient could be discharged after 14 days of hospital stay. Based on his age and the co-morbidities palliative treatment with 5-azacytidine was recently initiated. Patient 2 was admitted with PCR-confirmed SARS-CoV2 infection and suspected pneumonia. He reported dry cough and increasing weakness but no fever over the preceding two weeks. The patient was on current therapy with the known lymphodepleting-therapy consisting of four

This article is protected by copyright. All rights reserved cycles bendamustine and rituximab until September 2019, followed by three cycles rituximab maintenance therapy for follicular B-cell lymphoma (FLIPI Score 1) diagnosed six years ago. Four years ago he underwent surgery for renal cell cancer without subsequent radio-and chemotherapy. Additional risk factors were hypertension and obesity (BMI 31.9 kg/m²). On admission the patient reported fever for two days, he had 37.9°C temperature, leukopenia and reduced oxygen saturation of 90% and a pO2 of 55 mmHg. This was paralleled by dyspnea, and bilateral pneumonia was confirmed by CT. With inhalation therapy and combined oral favipiravir and prednisone from days 9 to 13 the oxygen need could be continuously reduced from 8 L/min to 1 L/min until day 10. Viral clearance was confirmed by two negative PCR tests for SARS-CoV2 from nasal swabs and complete resolution of respiratory symptoms the patient and the patient could be discharged thereafter as cured from COVID-19 thirteen days after admission. Patient 3 had a history of hairy cell leukemia diagnosed ten years ago. Two months ago 1% hairy cells were detected in the peripheral blood and thus a relapse was suspected. Ten days before admission the patient developed symptoms with coughing, fever, diarrhea and loss of appetite.

Three days later SARS-CoV2 RNA was tested positive in the swab. The patient´s condition worsened during the following week and he was therefore transferred to our department. Upon admission the temperature was 37.3°C, he had a leukopenia and tachypnea, and viral pneumonia was confirmed by chest X-ray. The oxygen saturation at ambient air was initially between 87% and with 6 L/min oxygen supply it increased to 91% and the patient was admitted to the ICU.

Because of the critical situation and the increased signs of inflammation (Table 1) Adverse outcomes with a fatality rate of up to have also been described in patients with different types cancer with a case fatality rate between 25 and 55 %, which, however, was lowest in subjects with haematological malignancies (8) . Along this line, a recent report presented the favorable outcome of Covid-19 infection in an infant with acute myeloid leukaemia (9) . Thus, the nature of the underlying malignant disease, anti-cancer treatment and immune status along with co-morbidities are likely decisive for the course and outcome of COVID-19 infection. In summary, we describe three cases of patients with hematological malignancies indicating that COVID-19 has a janus faced presentation in that patient group. While those patients may have increased susceptibility to viral infection and bacterial superinfection, they may not typically develop COVID-19 associated hyperinflammation in the later course of the disease. 

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Acknowledgement: None of the authors has a conflict of interest in association with that study.All listed authors contributed to the content of this study.

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