Successful Treatment of Prolonged, Severe Coronavirus Disease 2019 Lower Respiratory Tract Disease in a B cell Acute Lymphoblastic Leukemia Patient With an Extended Course of Remdesivir and Nirmatrelvir/Ritonavir

Abstract

A patient with B-cell acute lymphoblastic leukemia (ALL) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had persistent, progressive pneumonia with viremia after 5 months of infection despite monoclonal antibodies, IV remdesivir and prolonged oral steroids. Twenty days of nirmatrelvir/ritonavir and 10 days of IV remdesivir led to full recovery.

Successful Treatment of Prolonged Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Patients With Immunodeficiency With Extended Nirmatrelvir/Ritonavir: Case Series

“…The resolution of patient symptoms in all cases coincident with extended nirmatrelvir/ritonavir treatment in the presence of persistence following prior therapy suggests that this was an important factor in treatment. These cases add to and expand upon a previously published case report of clearance of SARS-CoV-2 following extended remdesivir and nirmatrelvir/ritonavir treatment in a patient with B-cell ALL and prolonged symptoms of SARS-CoV-2 infection [ 8 ].…”

“…The Food and Drug Administration (FDA) authorized a 5-day course of nirmatrelvir/ritonavir for mild-to-moderate coronavirus disease 2019 (COVID-19) under Emergency Use Authorization (EUA) [ 4–7 ]. One case report has described successful treatment utilizing a longer course of both nirmatrelvir/ritonavir and remdesivir in a patient with B-cell acute lymphoblastic leukemia (ALL) and prolonged SARS-CoV-2 infection [ 8 ]. Thus, there are limited data on treatment strategies for patients with B-cell depletion and prolonged infection with SARS-CoV-2, which represents an important gap in current knowledge.…”

Hospital‐at‐home care for immunodeficient patients with COVID‐19: Approach to persistent COVID‐19 infection

“…However, there are no standard guidelines for prolonged COVID‐19 patients. Thus, some experts administered remdesivir for more than 10 days for immunodeficient patients 13‐15 . Other experts chose the combination therapy of antiviral drugs and monoclonal SARS‐CoV‐2 antibody drugs because the antibody type has a relatively longer half‐life than the antiviral type, including remdesivir or nirmatrelvir–ritonavir 14‐16 .…”

“…Thus, some experts administered remdesivir for more than 10 days for immunodeficient patients. [13][14][15] Other experts chose the combination therapy of antiviral drugs and monoclonal SARS-CoV-2 antibody drugs because the antibody type has a relatively longer half-life than the antiviral type, including remdesivir or nirmatrelvir-ritonavir. [14][15][16] Although there are many expert opinions about the treatments in patients with prolonged COVID-19, it remains unclear which treatment should be chosen by primary care physicians engaging in HaH care (i.e., antiviral drugs only, monoclonal SARS-CoV-2 antibody drugs only, or both).…”

Dual antiviral therapy in haematological patients with protracted SARS‐CoV‐2 infection

“…Since the prolonged disease in this population reflects the persistence of active SARS-CoV-2, some cases of protracted COVID-19 have been treated with antivirals for an extended period of time, as recrudescence of symptoms has been described after 5 days of nirmatrelvir/ritonavir in the general population 5 and after 10 days of remdesivir in immunocompromised patients. 6 In haematological setting, remdesivir has been used as monotherapy for up to 30 days in subjects with pneumonia 6 ; another patient has been successfully treated with remdesivir plus nirmatrelvir/ritonavir 7,8 , as this combination showed in vitro a synergic activity against SARS-CoV-2 replication. 9 Due to protracted COVID-19 and haematological disease progression for chemotherapy delay, an off-label combination of remdesivir and nirmatrelvir/ritonavir was proposed to haematological patients with protracted COVID-19 or with persistent viral positivity needing chemotherapy.…”