Prolonged SARS-CoV-2 infection following rituximab treatment: clinical course and response to therapeutic interventions correlated with quantitative viral cultures and cycle threshold values

Abstract

Background Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA is completed through reverse transcriptase-PCR (RT-PCR) from either oropharyngeal or nasopharyngeal swabs, critically important for diagnostics but also from an infection control lens. Recent studies have suggested that COVID-19 patients can demonstrate prolonged viral shedding with immunosuppression as a key risk factor. Case presentation We present a case of an immunocompromised patient with SARS-CoV-2 infection demonstrating prolonged infectious viral shedding for 189 days with virus cultivability and clinical relapse with an identical strain based on whole genome sequencing, requiring a multi-modal therapeutic approach. We correlated clinical parameters, PCR cycle thresholds and viral culture until eventual resolution. Conclusions We successfully demonstrate resolution of viral shedding, administration of COVID-19 vaccination and maintenance of viral clearance. This case highlights implications in the immunosuppressed patient towards infection prevention and control that should consider those with prolonged viral shedding and may require ancillary testing to fully elucidate viral activity. Furthermore, this case raises several stimulating questions around complex COVID-19 patients around the role of steroids, effect of antiviral therapies in absence of B-cells, role for vaccination and the requirement of a multi-modal approach to eventually have successful clearance of the virus.

Viral cultures, Polymerase Chain Reaction Cycle Threshold Values and Viral Load Estimation for SARS-CoV-2 Infectious Potential Assessment in Hematopoietic Stem Cell and Solid Organ Transplant Patients: A Systematic Review

“…Antiviral drugs may impact on these observations, especially symptoms and viral burden. 19 Two well-designed studies on immunosuppressed patients, which we were unable to include because disaggregated data solely for transplant patients were not fully available, support our conclusions 6,20 . While this review is limited to transplant patients, evidence suggests similar prolonged viral cultures are found in immunosuppressed cancer patients.…”

Treatment of Long COVID with nirmatrelvir/ritonavir and tocilizumab in a patient with rheumatoid arthritis and SARS-CoV-2 antigen persistence: a case report

“…This case study described a Neuro-PASC patient presenting with long-term nasopharyngeal viral shedding as determined by SARS-CoV-2 antigen tests. Persistent viral colonization has been described previously both in the nasopharynx and extra-respiratory sites [13,14] and is associated with being immunocompromised [15], though it is unknown whether viral persistence is more common in PASC patients than in healthy COVID convalescents. In this case, the patient was on immunosuppressive therapy with tocilizumab for pre-existing rheumatoid arthritis when she contracted SARS-CoV-2, which may have contributed to viral persistence over 6 months.…”

Persistently positive PCR SARS-CoV-2 at low cycle threshold in an immunosuppressed patient

“…To our knowledge, relatively few cases of immunosuppressed patients with oncohematological malignancies and prolonged disease courses have been described. 3 …”