A Fatal Breakthrough COVID-19 Case with prolonged high viral load

An Asian man in his 70s developed a fever at home 11 days after his second dose of the mRNA vaccine BNT162b2 (disease day 0). On disease day 10, he was admitted to the hospital following to his worsened status. On arrival, his oxygen saturation was 56% while he was breathing ambient air. Remdesivir, methylprednisolone treatment was initiated along with a single dose of 8 mg/kg tocilizumab. He required a noninvasive, positive-pressure ventilator for hypoxemia. On disease day 19, his oxygen level abruptly dropped, and intubation was needed. On disease day 26, soon after extubation, he developed pneumothorax and acute respiratory distress syndrome. High SARS-CoV-2 viral load (Delta variant, although several mix alleles were found in the specimens collected on disease days 27-29) was observed until 1 month after onset. He died on disease day 31. 

One year before admission he successfully received six courses of bendamustine-rituximab (BR) therapy for stage 3 mucosa-associated lymphoid tissue (MALT) lymphoma with no evidence of relapse since then. 

The authors of this report attribute this fatal case to four causes: (i) impaired responsiveness toward SARS-CoV-2 vaccine, (ii) prolonged high SARS-CoV-2 viral load, (iii) difficulties in controlling T-cell immunodeficiency and cytokine storm, and (iv) the possibility of bacterial superinfection


Kamegai K, Iwamoto N, Togano T, Maeda K, Takamatsu Y, Miyazato Y, Ishikane M, Mizokami M, Sugiyama M, Iida S, Miyamoto S. A Fatal Breakthrough COVID-19 Case Following Bendamustine-Rituximab Therapy. International Journal of Infectious Diseases. 2022 Aug 1;121:85-8.


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