Prolonged viral shedding following COVID-19 infection in a rheumatoid patient on rituximab treatment

Sir, Since the beginning of the COVID-19 pandemic, we have seen several ways the disease can present, while it mostly manifests as a mild self-limiting upper respiratory infection in immune-competent individuals though a severe and variable course may be reported in individuals incidentally found to have latent immunodeficiencies. We report here a case of a patient with prolonged COVID-19 infection. A 50-year-old woman with a longstanding history of rheumatoid arthritis, receiving regular rituximab (RTX) infusions, experienced fatigue and malaise in November 2022, subsequently diagnosed with a COVID-19 infection. Despite initial conservative treatment, her condition escalated to high-grade fever, revealing bilateral peripheral infiltrates on a chest computed tomography scan, which were confirmed as Pseudomonas infection through bronchoscopic cultures. This infection responded positively to specific antibiotics [Figure 1].Figure 1: Timeline of clinical courseHowever, her fever relapsed, and the infiltrates were thought to have an autoimmune origin, leading to the diagnosis of organizing pneumonia. Consequently, steroid therapy was initiated in addition to antibiotic coverage for the presumed bacterial infection. Intriguingly, bronchoscopic fluid was found to be COVID-19 PCR positive in April, 5 months from the initial COVID-19 infection. Seeking further insights, she was referred to an immunologist who conducted a COVID-19 antibody assay. Surprisingly, the results indicated an absence of COVID-19 antibodies. Table 1 illustrates the decline in antibody levels over the years.Table 1: Immunoglobulin levels trends over yearsSubsequently, a multidisciplinary team convened to deliberate on the case. Given her medical history of immunocompromised status stemming from regular RTX infusions, a decision was made to administer oral antiviral treatment. Encouragingly, she displayed a favorable response to this therapeutic approach, leading to her discharge and return home [Figure 2].Figure 2: Serial computed tomography (CT) scans: (a and b) Fleeting infiltrates on CT scan done in January and April, respectively, and (c) Resolution after antiviral treatmentProlonged or severe COVID in young individuals has been linked to latent immunodeficiencies, which may be inherited or acquired.[1] Calderón-Parra et al. demonstrated in an extensive cohort of patients receiving anti-CD20 therapy within the last 6 months for various reasons that patients on therapy had a high incidence of hospital admission severe infection relapse and death.[2] Therefore, it is imperative for physicians to recognize the potential for extended viral shedding in individuals receiving RTX, underscoring the importance of promptly initiating antiviral treatment to mitigate patient morbidity. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.