Case Presentation: A 50-year-old female with rheumatoid arthritis who received 6-monthly maintenance Rituxan infusions, developed COVID-19 and was hospitalized with acute hypoxic respiratory failure. She was treated with 5 days of Remdesivir and discharged with 3L supplemental oxygen to complete a 10-day course of Dexamethasone. She didn’t improve to baseline and was re-hospitalized with progressively worsening dyspnea and hypoxemia, 28 days after discharge, with a positive COVID PCR. She required 11L high-flow oxygen to maintain saturations above 90% at rest. A CT scan of the chest revealed extensive multifocal ground-glass, consolidative pulmonary opacities and ruled out pulmonary embolism. She received a course of Remdesivir and Dexamethasone again for 5 days, followed by a 7-day course of Cefepime for possible hospital-acquired pneumonia. Given slow improvement, a repeat CT scan of the chest done 7 days later, showed worsening ground-glass opacities in upper lobes but improved in lower lobes. Due to concern for cryptogenic organizing pneumonia in the setting of COVID, steroids were restarted. Pulmonology and Infectious Disease were consulted. She received a monoclonal antibody infusion. Despite being on high dose steroids for about 10 days, there was no appreciable improvement in hypoxemia or her profound exertional dyspnea. Extensive workup for other etiologies was negative. A decision was made to treat her with Remdesivir again. She felt better after resuming Remdesivir and continued to show slow improvement with improved hypoxemia and was continued on an extended duration of 14 days. Following this, she still tested positive on COVID antigen and PCR tests. She was weaned down to 3L supplemental oxygen and was sent home on Nirmatrelvir/Ritonavir for 10 more days and advised to follow up in the Post-COVID clinic in 2 weeks. At her follow up visit, she continued to have continued exertional dyspnea but improving exercise tolerance with reduced oxygen requirement. Patient reported to feel the greatest clinical improvement after starting the Nirmatrelvir/Ritonavir. The patient is planned to have repeat imaging and PFTS with 6 min walk test in 6 months and has yet to restart any immune suppression for her rheumatoid arthritis.
Discussion: Hospitalists frequently encounter immunocompromised patients with COVID. Patients on Rituximab often are not able to mount a good humoral response against the COVID-19 virus and are at risk of severe disease, hospitalization, and death. There is mounting literature that these patients don’t respond to the vaccinations robustly. Prolonged viral shedding may be seen in these patients with reports suggesting shedding up to 189 days after the initial infection. These patients can be challenging to treat with routine strategies. There was a recent case report which used extended Remdesivir for 30 days with successful clearance of the virus [negative PCR] in an immunosuppressed COVID patient on Rituximab. Our case report similarly describes the utility of using extended antiviral therapy in this situation to help the patient clear the virus.
Conclusions: Immunosuppressed patients receiving Rituximab infusions are at risk of increased risk of severe disease and death from COVID; routine treatment strategies may prove ineffective.Although there are no standardized protocols or guidelines to treat such patients, extended therapy with antivirals- namely Remdesivir and Nirmatrelvir/Ritonavir may help achieve viral clearance and improve clinical outcomes.