key: cord-0909565-m6zc7wv0
authors: Tepasse, Phil‐Robin; Hafezi, Wali; Lutz, Mathias; Kühn, Joachim; Wilms, Christian; Wiewrodt, Rainer; Sackarnd, Jan; Keller, Martin; Schmidt, Hartmut H.; Vollenberg, Richard
title: Persisting SARS‐CoV‐2 viremia after rituximab therapy: Two cases with fatal outcome and a review of literature
date: 2020-06-01
journal: Br J Haematol
DOI: 10.1111/bjh.16896
sha: 52653346b36a5f6f0c74850d6d99795aea7b09f3
doc_id: 909565
cord_uid: m6zc7wv0

BACKGROUND: COVID‐19 is an emerging infectious disease caused by SARS‐CoV‐2. The role of immunosuppression in disease course is not clear. Here we describe the lethal disease course in two SARS‐CoV‐2 infected patients after rituximab therapy. METHODS: Clinical data and laboratory findings of two SARS‐CoV‐2 infected rituximab treated patients were collected. SARS‐CoV‐2 RNA was detected in blood. RESULTS: Both patients developed severe respiratory failure. SARS‐CoV‐2 viremia persisted in both patients until they died on day 22 and 26 after admission. CONCLUSION: Rituximab therapy leads to severe combined immunodeficiency and these two cases indicate a high risk for fatal outcome after SARS‐CoV‐2 infection.

COVID-19 is an emerging novel infectious disease caused by coronavirus SARS-CoV-2.

The virus was first described in Wuhan, China and meanwhile is spreading worldwide [1] .

Many studies all over the world suggest that older persons and patients with chronic disease (especially with chronic lung disease) are on higher risk for the development of SARS-CoV-2 related pneumonia (COVID-19) and respiratory failure [2] . If immunosuppressive treatment is a further risk factor or even has protective capabilities has not been elucidated so far. Historical data demonstrated higher risk for immunocompromised patients after different viral infections, for example Influenza infection. According to mortality data on MERS-CoV, SARS-CoV and SARS-CoV-2 infections, there is evidence that an immunosuppressive therapy alone may not determine a worse prognosis [3] . Immunocompromised patients after organ transplantation or with chronic inflammatory disease seem to be not extraordinarily affected of severe disease course after infection with coronaviruses (SARS, MERS and SARS-CoV-2) [4] . Standard medications after organ transplantation such as calcineurininhibitors interact primarily selective on T-lymphocytes and suppress its function, while Bcell activity largely remains. Mainly patients with haematological malignancies are treated with rituximab, an anti-CD20 antibody. Rituximab leads to complete B-cell depletion and therefore to severe combined immunosuppression and is possibly associated with severe disease course, contrary to existing data of other immunosuppressive drugs. Here we present two cases of SARS-CoV-2 infected patients after rituximab therapy with fatal outcome

This article is protected by copyright. All rights reserved

Two patients with SARS-CoV-2 infection and history of rituximab therapy were identified.

The patients´ charts were screened for patient history and actual clinical data and laboratory and radiological findings. SARS-CoV-2 viremia was detected by semiquantitative real-time PCR in peripheral blood in both the plasma and cellular fraction. EDTA plasma samples were processed using an integrated automated pipetting system for nucleic acid extraction and RT-PCR assay setup (Qiagen Symphony, DSP Virus/Pathogen Midi Kit, Qiagen AG, Hilden, Germany). Single-step RT-PCR primers and probes specific for SARS-CoV-2 E-gene, RdRP-gene, RNA positive controls, and RNA extraction control, respectively, were purchased from TIB molbiol GmbH, Berlin, Germany (LightMix Modular SARS and Wuhan CoV E-gene, Wuhan CoV RdRP gene, EAV RNA extraction control) [5] . Reverse-transcriptase, taq polymerase and nucleotides were obtained from ThermoFisher (Superscript III Platinum One-Step qRT-PCR Kit), ThermoFisher, Schwerte, Germany). Thermal cycling and fluorescence detection was inserted into the vector pCR-Topo-2.1 (ThermoFisher). Linearized plasmid DNA was added to SARS-CoV-2 negativ human plasma pool at a final concentration of 10 6 to 10 2 copies/mL, extracted as described above and a standard curve was calculated.

Both patients were male, 65 and 66 years old and of normal weight. Patient 1 suffered from cerebral relapse of diffuse large B-Cell lymphoma and arterial hypertension and was treated with R-DeVIC (Rituximab, Dexamethason, Etoposide, Ifosfamide, Carboplatin) for several months. The last therapy cycle was administered two weeks before infection with SARS-CoV-2. Patient 2 suffered from mantle cell lymphoma and chronic renal insufficiency. He was in complete remission and received maintenance therapy with

This article is protected by copyright. All rights reserved Rituximab (last cycle was administered two weeks before infection) and Ibrutinib daily. Bcells were completely depleted and immunoglobulin G was decreased in both patients.

Admission to our hospital was one day and four days after development of fever, respectively. SARS-CoV-2 RNA was detected in pharyngeal swabs. Neither of them showed hypoxia on the day of admission. High fever was persisting in both patients for the next 14-21 days. Besides SARS-CoV-2 infection there were no alternative foci present. Patient 1 developed hypoxia on day 4, patient 2 on day 9. Both patients got chest x-rays and thoracic CT imaging with detection of bilateral pulmonal peripheral ground glass infiltrates (Figure 1 

We present two immunocompromised patients with severe COVID-19 pneumonia with persisting viremia until death without any sign of viral clearance. Both patients developed a massive cytokine storm during disease course and died of progressive respiratory failure. Viremia is not typical in viral respiratory diseases. Usually diagnosis of pulmonary viral infection results from specimens from the oropharygeal and respiratory tract.

This article is protected by copyright. All rights reserved Therefore, the role of viremia in this strong immune reaction in these two cases remains speculative. There is evidence that viremia itself and the duration of the viremic period is correlated with increased morbidity [6] . Many COVID-19 patients develop a massive cytokine storm during severe disease course [7] . This immune reaction is possibly related to fatal outcome, as the host´s uncontrolled immune reaction after infection with zoonotic viruses seems to be a main driver of tissue damage [8] . Therefore immunosuppressive treatment is possibly effective by suppressing proinflammatory host reaction to SARS-CoV-2. Some studies showed therapeutic effects of immunosuppressive treatment in these patients, for example anti-IL-6 antibody treatment possibly improves disease course in COVID-19 by preventing lung tissue damage [9] . Available data of pandemic SARS, MERS and SARS-CoV-2 infections indicate that immunocompromised patients are not inevitable at higher risk for severe disease course [10] . 

This article is protected by copyright. All rights reserved might be dispensable in the immune response against SARS-CoV-2 and that remaining T-cell function might be sufficient to overcome infection [14] . Here we describe to fatal cases with persistent and over time increasing viremia without any sign of viral clearance.

Both patients were older and had hematological malignancies. Besides Rituximab Patient 2 was treated with Ibrutinib, a Bruton-Tyrosin kinase inhibitor, which targets Blymphocytes and inhibits the cell cycle. Patient 1 got Ifosfamid, Carboplatin and Etoposide, each cell cycle inhibitors and besides B-cell also effecting T-cell immunity.

Taken together, both patients had Rituximab therapy in common and were additionally immunocompromised because of further therapies. These two cases provide evidence that B-cell function might be one important mechanism in resolving SARS-CoV-2 viremia.

Those patients with depleted B-cell function and further risk factors such as additional oncologic therapies or higher age might be at high risk for fatal disease course after SARS-CoV-2 infection. Detection of SARS-CoV-2 viremia by real-time PCR. Viral load increased over time in

Coronaviridae Study Group of the International Committee on Taxonomy of V. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2

Therapy, and Mortality in Covid-19

Middle East respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission

How is immunosuppressive status affecting children and adults in SARS-CoV-2 infection? A systematic review

Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR

Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province

COVID-19 cytokine storm: the interplay between inflammation and coagulation

Host response to influenza virus: protection versus immunopathology

Tocilizumab for the Treatment of Severe COVID-19

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Replication of human coronaviruses SARS-CoV, HCoV-NL63 and HCoV-229E is inhibited by the drug FK506

Accepted Article

The authors have no competing interests.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.