Case 2
The second case consists of a more severe case of COVID-19 in an immunocompromised 31-year-old African American female with hypertension, hyperlipidemia, congestive heart failure and end stage renal disease (on hemodialysis since 2013 after renal transplant failed) in the setting of granulomatosis with polyangiitis (treated with rituximab every four months, administered in February and June 2020). She first tested positive for SARS-CoV-2 by RT-PCR from a sample obtained in March of 2020 when she was admitted to the hospital for fevers, myalgias, and coughing and a chest CT showing small bilateral pleural effusions and bibasilar atelectasis/consolidation. At the time of admission, RT-PCR testing was delayed such that results did not return until after her 3-day hospitalization ended, during which she was treated empirically for bacterial pneumonia. Subsequent screening testing for SARS-CoV-2 during hospital encounters for other medical needs was negative by RT-PCR in June and early August. In mid-August, she developed new dyspnea, fevers, and fatigue, and her chest x-ray showed mild pulmonary edema and trace bilateral pleural effusions. A point-of-care SARS-CoV-2 RT-PCR test was negative, and she was admitted for evaluation. After extensive workup for ongoing fever without an identifiable cause, she was retested for SARS-CoV-2 by RT-PCR and found to be positive 9 days after symptom onset, a result that was later confirmed with qRT-PCR (VL 167,000,000 copies/mL). She received supportive treatment and was discharged 10 days after her positive test on a 2 L/minute oxygen requirement. Due to the delay of over a week after her initial presentation in diagnosing her SARS-CoV-2 reinfection, she was not placed on COVID-19 isolation precautions resulting in the infection of 3 healthcare workers involved in her care. Serological testing on 3 samples taken over the course of her second hospitalization all resulted negative for IgG and IgM to SARS-CoV-2. Rituximab, an anti-CD20 antibody, is known to deplete B-cells and has been suggested to impair viral clearance of SARS-CoV-2 for prolonged periods in some cases [14,15], but in this case multiple negative tests over the 154 days between her episodes support true reinfection instead. Whether she had an initial serologic response to SARS-CoV-2 that rapidly waned, or never developed effective antibodies at all is unknown.