A Systematic Review of Prolonged SARS-CoV-2 Shedding in Immunocompromised Persons

Abstract

Background: Although reports have documented prolonged SARS-CoV-2 RNA detection in immunocompromised patients, few studies have systematically analyzed data on duration of SARS-CoV-2 in respiratory specimens of immunocompromised patients.

Methods: A systematic review was undertaken to describe SARS-CoV-2 RNA and infectious virus detection in immunocompromised patients from published data between January 1, 2020 and July 1, 2022. Patients were included if there was ≥ 1 positive SARS-CoV-2 RNA result in respiratory specimens collected > 20 days since symptom onset or first positive SARS-CoV-2 RT-PCR result.

Results: Of the 183 patients, 175 were symptomatic with 83 (47.4%) that experienced intermittent relapsing symptoms, while pneumonia was reported in 122 (66.7%). Immunocompromising conditions represented were hematologic malignancy treatment (89, 48.6%), solid organ transplant (47, 25.7%), autoimmune disease treatment (14, 7.7%), solid tumor treatment (3, 1.6%), HIV infection (15, 8.2%), and primary immunodeficiency (15, 8.2%). Median duration from the first to the last positive SARS-CoV-2 RT-PCR result was 56 days in upper respiratory and 60 days in lower respiratory tract specimens. Significant differences in median duration of SARS-CoV-2 RNA detection were observed between patients with and without pneumonia and for patients with hematologic malignancies compared to solid organ transplant patients. Among patients with viral culture performed, median duration of replication-competent SARS-CoV-2 was 60.5 days from symptom onset (maximum 238 days) and 59 days from first RT-PCR positive result (maximum 268 days).

Conclusions: Immunocompromised persons can have replication-competent SARS-CoV-2 in respiratory tissues for months, including while asymptomatic. Serial SARS-CoV-2 testing can inform the duration of isolation for immunocompromised patients with SARS-CoV-2 infection.

Keywords: COVID‐19; SARS‐CoV‐2; immunocompromised.

FIGURE 1

PRISMA flow chart of studies screened for inclusion.

FIGURE 2

Duration of SARS‐CoV‐2 RNA in symptomatic immunocompromised patients from (A) time from the first to the last positive SARS‐CoV‐2 RT‐PCR result (N = 168) and (B) time from symptom onset to the last positive SARS‐CoV‐2 RT‐PCR result by primary immunocompromising condition (N = 102). *Indicates significant difference between groups with 95% confidence. A = autoimmune disease treatment. H = hematologic malignancy treatment. HIV = human immunodeficiency virus infection. PI = primary immunodeficiency. ST = solid tumor treatment. T = solid organ transplant.

FIGURE 3

Duration of SARS‐CoV‐2 RNA in symptomatic immunocompromised patients with or without pneumonia diagnosis (N = 142; 122 with pneumonia; 20 without pneumonia). (A) Time from the first to the last positive SARS‐CoV‐2 RT‐PCR result (N = 134, 122 with pneumonia and 12 without pneumonia) and (B) time from symptom onset to the last positive SARS‐CoV‐2 RT‐PCR Result (N = 74; 67 with pneumonia; 7 without pneumonia).