Approach to prolonged viral pneumonia in immunocompromised patients with COVID-19

This is the authors' abstract. We don't add key points for this paper.

In immunocompromised patients, infection with SARS-CoV-2 may cause prolonged viral pneumonia. Due to limited clinical evidence, this phenotype is poorly addressed in guidelines and may therefore remain undiagnosed or inadequately treated. For clinical diagnosis of prolonged COVID-19 pneumonia, we propose the following diagnostic criteria: prolonged respiratory symptoms and/or fever beyond 30 days after symptom onset of COVID-19, in the presence of persistent radiologic features and persistently positive SARS-CoV-2 PCR and the absence of another apparent explanation. A negative PCR from the upper respiratory tract may not suffice to rule out prolonged viral pneumonia, as viral replication may be restricted to the lower respiratory tract. Alternative diagnoses should be considered in case of no response to empiric treatment. The differential diagnosis includes (co-)infection with a respiratory viral, bacterial or fungal pathogen, organizing pneumonia and other lung diseases. In case of prolonged mild symptoms in combination with radiologic evidence and persistently positive SARS-CoV-2, we propose a 5- or 10-day course of antiviral treatment followed by antibody treatment as the primary treatment option. However, the availability of these drugs may be limited and effectiveness strongly dependent on the variant of SARS-CoV-2. Successful repeated or combination courses with antivirals have also been described. Even though the phenotype of prolonged viral pneumonia in COVID-19 is described in literature, its epidemiology and mechanisms are still poorly understood. Therefore, our approach to this clinical problem is largely based on anecdotal evidence and expert opinion.