COVID-19 pneumonia in a patient with granulomatosis with polyangiitis on rituximab: case-based review

Abstract

A 77-year-old man with past medical history of granulomatosis with polyangiitis (GPA) on rituximab and prednisone, presented to the hospital with worsening cough and shortness of breath. He had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by nasal swab polymerase chain reaction (PCR) while asymptomatic, 6 weeks earlier. He started with cough and shortness of breath 2 weeks after his initial positive test. After developing symptoms, he tested negative twice by nasal swab PCR, but the PCR of his bronchioloalveolar lavage was positive for SARS-CoV-2. He did not develop antibodies against coronavirus. Prednisone 15 mg daily was continued, and he received remdesivir, and convalescent plasma with quick recovery. We reviewed the literature to search for similar cases. Our case suggests that SARS-CoV-2 infection in patients on rituximab may have an atypical presentation and the diagnosis may be delayed due to negative PCR testing in the nasal swab. Patients may benefit from treatment with convalescent plasma.

Keywords: Autoimmune rheumatic disease; B cell depletion; COVID-19; GPA; Granulomatosis with polyangiitis; Immunosuppression; Immunosuppressive treatment; Rituximab; SARS-CoV-2; Vasculitis.

Fig. 1

Computerized tomography of the chest revealed multifocal groundglass opacities throughout both lungs, predominantly surrounding vessels and most prominent in the right upper lobe with some foci of groundglass consolidation or more veins with some associated septal line thickening. The findings were concerning for multifocal hemorrhage related to acute exacerbation of GPA versus viral infection