D107-20 IVIG for Rituximab-treated Patients With Prolonged Covid-19: A Case Series

Abstract Introduction COVID-related lung injury arises from viral-mediated tissue destruction and the accompanying host response. Patients treated with rituximab, an anti-CD20 monoclonal antibody that depletes B-cells and impairs humoral immunity, are particularly susceptible to severe and persistent SARS-CoV-2 infection. Rituximab use has been linked to severe COVID-19 disease, prolonged viral shedding, and post-COVID pulmonary complications. Intravenous immunoglobulin (IVIG) has been proposed as an adjunctive therapy for COVID-19, but data in this population remains limited. We present a case series of four rituximab-treated patients with persistent COVID-19 infection who demonstrated clinical improvement after IVIG. Case Series Four adults receiving rituximab for hematologic malignancy or autoimmune disease developed persistent COVID-19 infection. All experienced prolonged or recurrent symptoms, persistent SARS-CoV-2 positivity, and ongoing radiographic evidence of infection or inflammation despite standard therapy. Quantitative immunoglobulins were low in all cases, and transbronchial biopsy in three patients revealed areas of organizing pneumonia (OP). Patient A: A 78-year-old woman with rheumatoid arthritis (RA) on rituximab had recurrent COVID-19 infection resulting in several hospitalizations for hypoxemia. SARS-CoV-2 PCR was repeatedly positive and cross-sectional imaging demonstrated persistent pulmonary opacities. After IVIG, her pulmonary opacities markedly improved and hypoxia resolved. Patient B: A 33-year-old man with mantle cell lymphoma on rituximab had recurrent fevers and progressive hypoxemia in the setting of persistent SARS-CoV-2 positivity. CT chest showed OP. Following IVIG, he experienced rapid symptomatic improvement, and interval imaging demonstrated resolution of pulmonary opacities. Patient C: A 55-year-old woman with IgG4-related disease on rituximab developed respiratory failure due to COVID-19 pneumonia. Despite standard COVID-19 treatment and steroids for OP, she had persistent respiratory failure and pulmonary infiltrates. After IVIG, her hypoxemia improved and she was discharged on room air. Patient D: A 66-year-old woman with RA, idiopathic thrombocytopenic purpura, and chronic lymphocytic lymphoma on rituximab had persistent SARS-CoV-2 positivity and pulmonary infiltrates. After receiving IVIG, her cross-sectional imaging improved. She continued to require treatment with rituximab and had recurrent COVID-19 infection that was again treated with IVIG. Conclusions Persistent COVID-19 infection and COVID-associated organizing pneumonia in rituximab-treated patients are difficult to treat due to profound humoral immune deficits. In this case series, treatment with IVIG was associated with clinical, radiographic, and virologic improvement. These findings support the hypothesis that immunoglobulin replacement may augment viral clearance in B-cell depleted individuals and may represent a therapeutic option for persistent SARS-CoV-2 infection in this high-risk population. Prospective studies are warranted to evaluate its efficacy. This abstract is funded by: None