Breakthrough long COVID in a patient with rheumatoid arthritis

A 37-year-old South Asian woman with a 7-year history of rheumatoid arthritis (on bi-weekly tocilizumab injections) tested SARS-CoV-2 positive 9 month after receiving her vaccination (JNJ-78436735). She experienced persistent headache and fatigue for >6 weeks after infection and continued to test intermittently antigen+ for 14 weeks post-infection despite no overt exposure to SARS-CoV-2 infected individuals. She lived alone, did not leave her residence without a surgical-grade N95 mask, and never removed the mask in public. She was subsequently prescribed a 5-day course of nirmeltravir/ritonavir 300/100 mg twice daily. Initially, all PASC symptoms resolved, and the patient tested antigen negative 3 weeks after completion of nirmeltravir/ritonavir, but the symptoms and antigen positivity subsequently reappeared at 4 weeks (see figure). Assessment of adaptive immune responses demonstrated that nirmatrelvir/ritonavir and tocilizumab treatment decreased antiviral and autoreactive T cell activation. The patient halted tocilizumab therapy for RA upon her rheumatologist’s recommendation for 10 days in an attempt to fully clear the virus, during which time she developed more severe post-acute sequelae of COVID-19 (PASC) symptoms and the appearance of new-onset cognitive impairment (brain fog). She resumed tocilizumab and within 3 weeks her fatigue and brain fog had resolved while the occipital headache decreased in severity (Panel C in the Figure above).   However nasopharyngeal antigen positivity remained. 

Analysis of antiviral T cell responses by IFN-γ ELISPOT showed that Spike-specific T cell activation was induced by vaccination and infection, as expected after receiving Spike protein-based vaccines. The patient’s non-Spike responses (to Nucleocapsid) were enhanced as well after receiving the Moderna vaccine booster dose. Nirmatrelvir/ritonavir treatment resulted in the retention of Spike- but not Nucleocapsid-specific T cell responses, while halting tocilizumab correlated with elevated T cell responses against both proteins. Resumption of tocilizumab subsequently decreased T cell responses to both viral antigens.

The patient’s mild acute symptoms combined with an escalation in Neuro-PASC symptom severity after stopping tocilizumab, as well as their resolution after resuming treatment suggests that IL-6 blockade should be studied further as a potential therapeutic intervention for Neuro-PASC.


REFERENCE

Visvabharathy L, Orban ZS, Koralnik I. Case Report: Treatment of long COVID with a SARS-CoV-2 antiviral and IL-6 blockade in a patient with rheumatoid arthritis and SARS-CoV-2 antigen persistence. Frontiers in Medicine.:2832.

Comments

Post a Comment

Popular posts from this blog

A New Onset of Ulcerative Colitis post-2nd-breakthrough-COVID-19

Image
A 21-year-old non-smoking Caucasian male with a history of acute pancreatitis but no other medical issues or family history had two doses of the BNT162b2 mRNA COVID-19 vaccine.  Four months after the second dose he had his first episode of COVID-19. Although not hypoxic, he felt pretty unwell for a week, with a severe cough, fever, generalized body ache, headache, and loss of taste. He received the third dose of the vaccine two months after recovering from COVID. Nine months after the third dose, he had the second episode of COVID-19, during which he was mildly unwell for three days, recovered, and did not require any anti-viral medication or antibiotics. One week post the second episode of COVID-19, he developed diarrhea and abdominal pain. It then progressed to bloody diarrhea. Ulcerative colitis was diagnosed based on his clinical symptoms, biopsy changes, and the exclusion of other causes.  There are ten published case reports about the newly diagnosed ulcerative colitis associate
Read more

COVID in May

Image
Concerns about a potential resurgence of COVID-19 are mounting as summer 2024 approaches.  This is driven by several indicators, including social media posts, healthcare data, and wastewater surveillance across different regions. Our study findings corroborate this trend.  While many forecasters anticipate a surge, others expect a gradual increase through the end of May, and then a decline again around early June. Reports from social media suggest emerging clusters of COVID-19 in Texas, several Canadian provinces, the UK, and on cruises in northern regions such as a Norwegian cruise to Alaska.  Data from Alberta's Respiratory virus dashboard   (total weekly laboratory-confirmed COVID-19 cases) and wastewater surveillance in Calgary indicate an uptick in COVID-19 cases starting April 2024. The most recent statistics from Alberta Health reveal a significant increase in hospitalizations due to COVID-19, with 114 individuals currently hospitalized—an increase of more than 20% over two
Read more

Chronic SARS-CoV-2 Shedding

Image
Chronic viral shedding, a condition where the virus continues to be released from an individual's body long after the initial infection, has been observed in many infectious diseases, including COVID-19.  In such cases, individuals may remain asymptomatic or experience only mild symptoms while the virus persists. It remains detectable in repeated tests over an extended period and can still infect others even in nasal swab is negative (which happens quite often ). This was evident in our study.    Recent research by Conway et al. (2024) highlights the possibility of chronic SARS-CoV-2 infection, extending over several months and potentially years. Other studies have documented prolonged asymptomatic infections and extended viral shedding in moderate to severe beyond hospital discharge. Analysis of sequencing data on UK samples taken between 2 November 2020 and 15 August 2022 lead to estimates that 0.1–0.5% of infections may become persistent with typically rebounding high viral load
Read more