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29 June 2024 : Case report  Italy

A 67-Year-Old Man with Chronic Lymphocytic Leukemia (CLL) on Maintenance Therapy with Ibrutinib with Persistent SARS-CoV-2 Infection Unresponsive to Antiviral Treatments

Unusual clinical course, Challenging differential diagnosis, Unusual or unexpected effect of treatment

Flavia Sanmartin1ABCDEF*, Eugenia Magrini1ABCDEF, Emanuele Rando1CDEF, Paola Del Giacomo2AF, Alex Dusina2AF, Elena Matteini1B, Andrea Carbone1B, Giuseppe Puma1B, Gabriele Maria Leanza1B, Federico Frondizi1B, Idanna Innocenti3C, Giuseppe Maiuro2A, Flora Marzia Liotti2ABCDE, Rosaria Santangelo2CD, Luca Laurenti3AB, Antonella Cingolani2ABDE

DOI: 10.12659/AJCR.941165

Am J Case Rep 2024; 25:e941165

Abstract

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BACKGROUND: SARS-CoV-2 infection can persist in immunocompromised patients with hematological malignancies, despite antiviral treatment. This report is of a 67-year-old man with chronic lymphocytic leukemia (CLL), secondary hypogammaglobulinemia, and thrombocytopenia on maintenance therapy with ibrutinib, with persistent SARS-CoV-2 infection unresponsive to antiviral treatment, including remdesivir, nirmatrelvir/ritonavir (Paxlovid), and tixagevimab/cilgavimab (Evusheld).

CASE REPORT: The patient was admitted to our hospital 3 times. During his first hospitalization, he was treated with 5-day course of remdesivir and intravenous steroids; however, antigen and molecular nasopharyngeal swabs were persistently positive, and he was discharged home. Due to respiratory worsening, he was rehospitalized, and despite being treated initially with tixagevimab/cilgavimab, and subsequently with a remdesivir course of 5 days, SARS-CoV-2 tests remained persistently positive. During his third hospital stay, our patient was subjected to combined therapy with remdesivir and nirmatrelvir/ritonavir for 5 days, obtaining a significant reduction of viral load at both antigen and molecular testing. As an ultimate attempt to achieve a negative status before discharge, a 10-day course of combined remdesivir and nirmatrelvir/ritonavir was administered, with a temporary reduction of viral load, followed by a sudden increase immediately after the discontinuation of Paxlovid. Due to worsening hematological disease and bacterial over-infections, the patient gradually worsened until death.

CONCLUSIONS: This is an emblematic case of correlation between persistent SARS-CoV-2 infection and immunosuppression status in hematological hosts. In these patients, the viral load remains high, favoring the evolution of the virus, and the immunodeficiency makes it difficult to identify the appropriate therapeutic approach.

Keywords: case reports, COVID-19, Immunocompromised Host, SARS-CoV-2, Nirmatrelvir and Ritonavir Drug Combination, Remdesivir

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923