key: cord-0866162-anrt8m79
authors: Barzegar, Mahdi; Mirmosayyeb, Omid; Nehzat, Nasim; Sarrafi, Reza; Khorvash, Farzin; Maghzi, Amir-Hadi; Shaygannejad, Vahid
title: COVID-19 infection in a patient with multiple sclerosis treated with fingolimod
date: 2020-05-05
journal: Neurol Neuroimmunol Neuroinflamm
DOI: 10.1212/nxi.0000000000000753
sha: d6a8bb42b5410adc294fca31c55a2cd3b02e6ec6
doc_id: 866162
cord_uid: anrt8m79

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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), and slight decrease in blood pressure (100/70 mm Hg) and in oxygen saturation (89%) with a decrease in lymphocyte counts to 440.8/μL. Fingolimod was stopped because of concern for sepsis. Ceftriaxone 1 g twice daily was added and started on oxygen via a nasal cannula. Chest CT was performed to rule out pulmonary embolism, given her history; however, it was indicative of ground glass opacities (figure, B). 3 Given the clinical and imaging findings, COVID-19 was suspected, and a nasopharyngeal swab was obtained and sent to the Isfahan University of Medical Sciences reference laboratory for real-time PCR testing for COV. She was transferred to the special COVID ward and received a combination of hydroxychloroquine, oseltamivir (to cover for influenza), and piperacillin/tazobactam, whereas ceftriaxone and azithromycin were discontinued. Three days later (11th March), she felt well and vital signs were stabilized, and she became afebrile and the lymphocyte counts increased to 510.3/μL. On March 12, the COVID-19 test was reported positive, and all other medications except hydroxychloroquine were discontinued. The symptoms of cough and dyspnea together with neurologic symptoms gradually improved. She was discharged after a 13-day admission and started on glatiramer acetate to avoid potential MS rebound after the discontinuation of fingolimod (lymphocyte count: 1,000.5/ul). Until the last televisit (30 March), she has been self-quarantined at home with no respiratory or neurologic symptoms. Given that she did not get a new MRI during the admission because of hemodynamic instability and also testing positive for COVID, it remains unclear whether her neurologic symptoms were because of the new disease activity (relapse) or worsening of preexisting symptoms (pseudorelapse).

Because most patients with immune-mediated disorders such as MS are treated with immunosuppressive agents, it is hypothesized that this patient population is at a higher risk for developing severe COVID-19. Consensus statements mostly recommend cautious in the use and initiation of high-efficacy medications and deem the lower-efficacy medications safer during the pandemic. 4 Therapeutic decision-making is more challenging in patients with active COVID-19 in whom discontinuation of immunotherapies could lead to rebound disease activity (e.g., fingolimod). 5, 6 In our patient, despite multiple comorbidities, the COVID-19 was resolved with good outcome, and there was no need for intensive care unit or intubation. Of note is that the initial presentation of COVID-19 was worsening of neurologic symptoms, which is commonly seen in patients with MS in context of infections. 7 As a result, pseudoexacerbations or relapses without a clear etiology should prompt COVID-19 testing during the pandemic.

No targeted funding reported. 

Clinical characteristics of coronavirus disease 2019 in China

Infection risks among patients with multiple sclerosis treated with fingolimod, natalizumab, rituximab, and injectable therapies

Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection

The COVID-19 pandemic and the use of MS disease-modifying therapies

Fingolimod rebound: a review of the clinical experience and management considerations

Dramatic rebounds of MS during pregnancy following fingolimod withdrawal

Infection as an environmental trigger of multiple sclerosis disease exacerbation