Case Report: Complete and Fast Recovery From Severe COVID-19 in a Pemphigus Patient Treated With Rituximab

Abstract

COVID-19 is characterized by a severe pulmonary disease due to severe acute respiratory syndrome (SARS)-CoV-2 infection. For clinicians involved in the management of patients with chronic autoimmune diseases the risk linked to the conditions itself and to drug-induced immunosuppression during the COVID-19 pandemic is a major topic. Pemphigus is a rare autoimmune blistering disease (AIBD) of the skin and mucous membranes caused by autoantibodies to desmosomal components, desmoglein 1 and 3. Among immunosuppressant therapies, rituximab (RTX) is considered a highly effective treatment with a favorable safety profile, but it induces a prolonged B-cell depletion that can lead to higher susceptibility to infections. For this reason, concerns about its use during the pandemic have been raised. We describe a case of a pemphigus patient in which RTX-induced B cell depletion led to the severe inflammatory phase, whereas corticosteroid treatment allowed a favorable outcome.

COVID ‐19 severity and SARS‐Cov ‐2 vaccine safety in pemphigus patients

“…The data of a pemphigus foliaceus patient who was infected by SARS‐CoV‐2 2 months after RTX infusion were reported. She required hospitalization but did not need intensive care, and she completely recovered 2 . An article from Italy reported that 19.4% of AIBDs patients experienced mild to moderate symptoms, while one PV patient (3.2%) with previous breast cancer required hospitalization but later recovered 14 .…”

“…She required hospitalization but did not need intensive care, and she completely recovered. 2 An article from Italy reported that 19.4% of AIBDs patients experienced mild to moderate symptoms, while one PV patient (3.2%) with previous breast cancer required hospitalization but later recovered. 14 Shahidi‐Dadras et al reported five COVID‐19 cases with a mild or moderate course in the total 45 RTX treated pemphigus patients.…”

“…1 Older age, male sex, and certain comorbidities, including diabetes, obesity, lung, heart, and kidney diseases, were determined as mortality risk factors for COVID-19. 2 Systemic corticosteroids and immunosuppressive drugs, especially rituximab, are mainstays of pemphigus treatment. Concerns over rituximab treatment are originated from the damage on B-cells which generally takes more than 6 months to recovery.…”

Clinical Dermatology and COVID-19 Pandemic

“…[ 89 ] A case report also documents the uncomplicated recovery of a COVID-19-infected patient with pemphigus vulgaris who had received a top-up dose of rituximab to control disease flare shortly before infection. [ 90 ] Because of associated prothrombotic risk, patients suffering from comorbid autoimmune blistering disorders and COVID-19 may benefit from low-dose aspirin to reduce morbidity and mortality rates. [ 91 ] Patients on recurrent rituximab dosing may benefit from immunoglobulin level testing.…”

A Novel Combined Use of Dupilumab for Treatment of Aggressive Refractory Pemphigus Vulgaris Complicated With Pulmonary Tuberculosis: A Case Report and the RNA-seq Analysis

“…Based on the conditions above, the dose of methylprednisolone could not be further increased. It is also difficult to use rituximab which may induce a prolonged B-cell depletion and aggravate infections ( 7 ). To improve therapy, dupilumab (600 mg subcutaneously initially and 300 mg subcutaneously every other week) was added to his regimen combined with methylprednisolone, anti-TB regular regimen, and antibiotics plus low-dose intravenous immunoglobulin (15 g IVIG for 4 d) for anti-infection ( Figure 2A ).…”