Comprehensive Treatment of Hematological Patients with SARS-CoV-2 Infection Including Anti-SARS-CoV-2 Monoclonal Antibodies: A Single-Center Experience Case Series

Abstract

Patients with hematologic malignancies are at high risk of exacerbated condition and higher mortality from coronavirus disease 2019 (COVID-19). Bamlanivimab, casirivimab/imdevimab combination, and sotrovimab are monoclonal antibodies (mABs) that can reduce the risk of COVID-19-related hospitalization. Clinical effectiveness of bamlanivimab and casirivimab/imdevimab combination has been shown for the Delta variant (B.1.617.2), but the effectiveness of the latter treatment against the Omicron variant (B.1.1.529) has been suggested to be reduced. However, the tolerability and clinical usage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific mABs in patients with hematologic malignancies are less specified. We present a retrospective case series analysis of all SARS-CoV-2-infected patients with hematologic malignancies who received SARS-CoV-2-specific mABs at our facility between February and mid-December 2021. A total of 13 COVID-19 patients (pts) with at least one malignant hematologic diagnosis received SARS-CoV-2-specific mABs at our facility, with 3 pts receiving bamlanivimab and 10 pts receiving casirivimab/imdevimab combination. We observed SARS-CoV-2 clearance in five cases. Furthermore, we observed a reduction in the necessity for oxygen supplementation in five cases where the application was administered off-label. To the best of our knowledge, we present the largest collection of anecdotal cases of SARS-CoV-2-specific monoclonal antibody use in patients with hematological malignancies. Potential benefit of mABs may be reduced duration and/or clearance of persistent SARS-CoV-2 infection.

Keywords: COVID-19; SARS-CoV-2; antibody therapy; bamlanivimab; cancer; casirivimab; hematologic malignancies; imdevimab.

Figure 1

Course of treatment of case 7. X-axis was modified to emphasize the period at our facility. Day 0 (Y-axis) signifies the onset of symptoms. PCRs with nonmeasurable results were set at 41 (above detection limit). Continuous/repeated applications are connected by a line. The patient was transferred to our facility with an increasing need for oxygen supplementation. Roughly a week after the described multiple interventions, the effects were seen with increasing Ct values.

Figure 2

Course of treatment of case 9. X-axis was modified to emphasize the period at our facility. Day 0 (Y-axis) signifies the onset of symptoms. PCRs with nonmeasurable results were set at 41 (above detection limit).

Figure 3

Course of the disease of case 10. X-axis was modified to emphasize the period at our facility. Day 0 (Y-axis) signifies the onset of symptoms. PCRs with nonmeasurable results were set at 41 (above detection limit).

Figure 4

Course of the disease of case 13. X-axis was modified to emphasize the period at our facility. Day 0 (Y-axis) signifies the onset of symptoms. PCRs with nonmeasurable results were set at 41 (above detection limit). The patient received casirivimab/imdevimab and was discharged to home quarantine. He presented several negative PCR swabs before readmission and started systemic therapy with azacitidine and venetoclax. Upon routine testing, low Ct values consistent with reactivation (a reinfection was ruled out by sequencing) were observed, quickly resolving after pausing azacitidine and venetoclax. After restart of therapy, the Ct values again decreased. Note: more than 50 days after casirivimab/imdevimab infusion (anti-SARS-CoV-2 spike protein IgG > 40,000 AU/mL at our facility), the patient had remaining anti-SARS-CoV-2 spike protein IgG titer of 26,440 AU/mL.