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.