Case Presentation: An 81-year-old Caucasian gentleman, with history remarkable for coronary artery disease with coronary artery bypass graft, heart failure with reduced ejection fraction, atrial fibrillation, acute kidney injury on chronic kidney disease, type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease and bronchiectasis, was admitted for initial symptoms of worsening shortness of breath. The patient had been recently vaccinated with the Moderna COVID-19 vaccine. Despite being fully vaccinated, the patient was diagnosed with COVID-19 disease. During that hospitalization, he was also diagnosed with non-Hodgkin’s B-cell lymphoma based on persistent leukocytosis with lymphocytic predominance in the setting of negative bacterial cultures and broad-spectrum antibiotics, as well as positive flow cytometry and fluorescence in-situ hybridization analysis.As the patient’s RNA polymerase chain reaction was positive at low cycle threshold indicating a high level of viremia, underlying non-Hodgkin’s B-cell lymphoma most likely explained why he did not respond well to the vaccine. He was treated with the hospital-established protocol of dexamethasone, tocilizumab, and remdesivir plus 2 courses of vancomycin and cefepime. The course was complicated by acute respiratory distress syndrome, requiring high doses of steroids. He did not have a protective antibody response. A probable pulmonary embolism based on ventilation/perfusion scan necessitated Lovenox. In spite of high oxygen supplementation in the form of non-invasive ventilation, he died.
Discussion: There is evidence that immunogenicity of COVID-19 vaccines may be attenuated in immunocompromised populations (1). One key question is if there is a way to ensure successful immunization against SARS-CoV-2 in patients with hematologic malignancies. There are ongoing clinical trials globally examining peripheral blood from patients with lymphoid cancers before and after their COVID-19 vaccination, looking for antibodies to SARS-CoV-2 and T-cell responses to the spike protein (2, 3). It has been difficult to distinguish between the effect of the lymphoma versus treatment for lymphoma on the data in currently available studies.Patients with indolent lymphomas might have impaired serological responses and may benefit from further measures, such as boosting with alternative vaccines or prophylactic monoclonal antibodies against SARS-CoV-2 (4,5).It is imperative to continue transmission mitigation measures to help protect vulnerable patients with cancer from SARS-CoV-2 exposure, infection, and life-threatening outcomes.
Conclusions: COVID-19 vaccination produces an immune response in 98% of normal healthy adults but only 55% of patients with hematologic malignancy (1). In several prospective studies, findings highlight heterogeneity in the immune response to COVID-19 vaccines based on underlying immunosuppressive condition (1, 6, 7). This underscores the urgent need to optimize and individualize COVID-19 prevention in these patients.
