Case Presentation: A twenty-year-old female with acute lymphoblastic leukemia presented to the ED with one day of fever and a non-productive cough. Her vitals were significant for a fever of 102.8 F. Lung auscultation revealed diminished air entry to the right lower lung field. The rest of her physical exam was unremarkable.Chest radiograph demonstrated a large right pleural effusion. She was neutropenic (ANC 486/µL) and anemic (hemoglobin 8.8 g/dL). She was started on vancomycin and cefepime on admission and was transfused 10 cc/kg of packed red blood cells.A SARS-CoV-2 PCR test resulted positive on hospital day (HD) 2. She was given a five-day course of hydroxychloroquine. On HD 4, vancomycin and cefepime were replaced with meropenem and clindamycin. Due to persistent fever and neutropenia, she was started on empiric intravenous voriconazole. Her persistent pleural effusion prompted a thoracentesis on HD 14. Six hundred milliliters of straw-colored pleural fluid were removed. Bacterial and acid-fast bacilli cultures from the pleural fluid remained sterile. Aerobic and fungal blood cultures remained negative.

Discussion: The impact of SARS-CoV-2 on cancer patients is unknown. Early epidemiologic data suggests that immunocompromised patients are at increased risk of SARS-CoV-2 infection [1]. However, information regarding the manifestations of COVID-19 in patients with cancer is still evolving. Liang et al [2] reported an increased incidence of cancer in a COVID-19 cohort compared to the general Chinese population. They also reported that patients with cancer had a higher risk of ICU admission, invasive ventilation, and death. Current United States estimates [1] of the prevalence of underlying conditions among patients with COVID-19 indicate that 3.7% of cases with complete clinical information had an immunocompromising condition. A small Chinese cohort study demonstrated increased severity and case fatality among persons with hematologic cancer and COVID-19 [3]. Our literature search identified 5 case reports describing the manifestations of SARS-CoV-2 infection in cancer patients. These include pneumonia in a 39-year-old male with chronic lymphocytic leukemia [4], pneumonia with effusion in a 60-year-old female with metastatic breast cancer [5], pneumonia in a 60-year-old male with multiple myeloma [6], pneumonia in a 62-year-old male with colon cancer [7], and pneumonia in a child with acute leukemia [8].Pleural effusion from COVID-19 as observed in our patient is uncommon [9], though it was observed in 3 of the 5 aforementioned case reports. The effect of administered therapies on her outcome, particularly hydroxychloroquine, is unclear. There is growing evidence to support a lack of clinical benefit from hydroxychloroquine [10]. The patient’s fever persisted after hydroxychloroquine was completed and defervescence occurred within 24 hours of voriconazole initiation. We theorize that voriconazole likely would not have had such a rapid effect, this improvement was likely not from voriconazole.

Conclusions: In conclusion, this report is the first description of COVID-19 in a young adult with acute leukemia. Even with significant immunosuppression and a moderate pleural effusion, the patient did not have respiratory failure or multi-organ dysfunction. The patient’s COVID-19 was managed with hydroxychloroquine and thoracentesis. Our experience suggests that immunocompromised patients with COVID-19 may experience a benign clinical course.