Mild or no COVID-19 symptoms in cladribine-treated multiple sclerosis: Two cases and implications for clinical practice

Abstract

Background The use of disease-modifying therapies (DMTs) in multiple sclerosis (MS) could affect COVID-19 outcomes by modulating the immune response, which, in turn, might favor viral replication and/or confer protection from COVID-19 induced inflammatory response Case report We report on two MS patients treated with cladribine, with heterogeneous demographics and clinical features, who developed mild or no symptoms from COVID-19 and produced anti-SARS-CoV-2 antibodies, notwithstanding low lymphocyte levels. Implications Benign COVID-19 clinical course and anti-SARS-CoV-2 antibody production can occur in MS patients with lymphopenia, suggesting the possibility to respond to COVID-19 vaccination, once available, in this vulnerable population.

COVID-19 with no antibody response in a multiple sclerosis patient treated with cladribine: Implication for vaccination program?

“…This is in line with previous observations by other authors ( Dersch et al., 2020 ; Jack et al., 2020 ; Celius, 2020 ; Preziosa et al., 2020 ; De Angelis et al., 2020 ). COVID-19 has been reported in 52 patients treated with cladribine; only in 23 of them, SARS-CoV-2 infection was confirmed by a laboratory test (i.e., nasopharyngeal swab and/or serological test) ( Dersch et al., 2020 ; Jack et al., 2020 ; Celius, 2020 ; Preziosa et al., 2020 ; De Angelis et al., 2020 ). In the remaining 39 patients, COVID-19 was suspected according to clinical symptoms and laboratory tests were not performed or tested negative ( Jack et al., 2020 ; Preziosa et al., 2020 ).…”

“…In the remaining 39 patients, COVID-19 was suspected according to clinical symptoms and laboratory tests were not performed or tested negative ( Jack et al., 2020 ; Preziosa et al., 2020 ). In all reports, cladribine-treated patients had favorable outcomes, even in the presence of severe lymphopenia ( Dersch et al., 2020 ; De Angelis et al., 2020 ), with no deaths nor need for mechanical ventilation. Serological data were available only for eight patients; and only one of them did not develop antibody response following infection ( Preziosa et al., 2020 ).…”

“…Cladribine is a highly effective oral DMD exerting its action through a sustained but transient lymphocyte depletion, with negligible effects on innate immunity ( Dersch et al., 2020 ). Few papers reported favorable COVID-19 outcomes in MS patients treated with cladribine ( Dersch et al., 2020 ; Jack et al., 2020 ; Celius, 2020 ; Preziosa et al., 2020 ; De Angelis et al., 2020 ).…”

SARS-CoV-2/COVID-19 in multiple sclerosis patients receiving disease-modifying therapy

“…The course of COVID-19 infection is mild in most patients [ 16 , 17 ]. Despite the published case reports, both the risk of infection and the course of COVID-19 in patients with MS are still unclear [ 15 , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] ]. It is known that patients with MS are generally more susceptible to infections [ 11 , 37 ], especially those with a higher degree of disability or serious comorbidities.…”

Impact of disease‐modifying drugs on the severity of COVID‐19 infection in multiple sclerosis patients

“…In this regard, it seems that cladribine does not increase the severity of COVID‐19 and does not disturb anti‐SARS‐CoV‐2 antibody production. Therefore, it has been suggested that cladribine could be considered as a proper drug in terms of COVID‐19 vaccination 42 …”