SEVERE COVID-19 PNEUMONIA IN A FULLY VACCINATED IMMUNOCOMPROMISED PATIENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Vaccinations against Novel Coronavirus 2019 (COVID-19) for immunocompromised individuals have been increasingly prioritized to avoid severe infection. Here is a case of severe COVID-19 infection in a patient with malignant lymphoma who completed the vaccination course. CASE PRESENTATION: A 79-year-old male with malignant lymphoma on active Rituximab was diagnosed with COVID-19 two months after completing the Pfizer vaccination course. He presented with a worsening cough despite receiving monoclonal antibodies outpatient. On evaluation, his vitals were stable. Chest x-ray revealed bilateral pleural effusions with bibasilar opacities. During his hospitalization, he received a full course of dexamethasone, ivermectin, remdesivir and baricitinib. However, his cough and oxygenation progressively worsened, with eventual intubation and vasopressor support. Computed Tomography (CT) Chest showed progressive worsening of COVID-19 Pneumonia. Originally on admission he had tested negative for the IgM and IgG antibodies against the Nucleocapsid (N) Protein which raised the suspicion that he had not mounted an immune response to the vaccine. On further evaluation, he was found to have positive antibody titers against Spike (S) proteins which confirmed that he had mounted a response to the vaccine despite his immunocompromised status. DISCUSSION: Anti-CD20 therapy is one of the primary therapies for hematological malignancies. Despite T cell function being the primary role against COVID-19, there is increasing evidence that B-cell depletion may inhibit protective immunity following infection and vaccination. A two-dose regimen of BNT162b2 (Pfizer) conferred 95% protection against COVID-19 in persons 16 years of age or older, and decreased the rate of severe infection. However, only 4% of the vaccinated patients suffered from any malignancy;0.2% of them had metastatic solid tumors, leukemia, lymphoma and none were on chemotherapy. The efficacy of the vaccine was extrapolated to include the subset of individuals on active chemotherapy. Interestingly, despite having an active immunological response to the vaccine and normal T-cell function, the patient suffered from severe COVID pneumonia. CONCLUSIONS: Though widespread immunization against COVID-19 is underway, patients with hematological malignancies still remain a vulnerable population. The decision to halt immunomodulatory therapy to improve efficacy of the vaccine needs further investigation. REFERENCE #1: Baker D et al. (2020). COVID-19 vaccine-readiness for anti-CD20-depleting therapy in autoimmune diseases. Clinical & Experimental Immunology, 202(2), 149–161. https://doi.org/10.1111/cei.13495 DISCLOSURES: No relevant relationships by Luke Alessi, source=Web Response No relevant relationships by Louis Avvento, source=Web Response No relevant relationships by Abdul Qadeer, source=Web Response No relevant relationships by Kathryn Saxby, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by LAKSHMI SUBRAMANIAN, source=Web Response No relevant relationships by Daisy Young, source=Web Response