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. 2025 Jul 21;11(3):e005756.
doi: 10.1136/rmdopen-2025-005756.

Persistent-relapsing SARS-CoV-2 infection following rituximab treatment for autoimmune rheumatic diseases: diagnosis and outcomes

Katerina Chavatza  1 , Elisavet Mastrostamati #  2 , Charalampos Charalampidis #  2 , Elvira-Markela Antonogiannaki #  3 , Ioannis Grigoropoulos  2 , Emmanouil Karofylakis  2 , Foteini Gkolemi  2 , Georgios Koromvokis  2 , Electra Kalara  2 , Eleni Sambatakaki  1 , Antonis Fanouriakis #  4 , Konstantinos Thomas #  2
Affiliations

Persistent-relapsing SARS-CoV-2 infection following rituximab treatment for autoimmune rheumatic diseases: diagnosis and outcomes

Katerina Chavatza et al. RMD Open. .

Abstract

Background: COVID-19 may persist or relapse in patients on B-cell depleting biologic therapies.

Objective: To examine the rate and outcome of persistent-relapsing COVID-19 (prCOVID-19) in patients with autoimmune rheumatic diseases (AIRD) treated with rituximab (RTX).

Methods: Single-centre, retrospective cohort study of patients diagnosed with prCOVID-19 (June 2021 to January 2025). prCOVID-19 was defined as persistence of symptoms and lung imaging findings for >30 days, along with persistently positive or PCR-based conversion in upper or lower respiratory tract samples.

Results: 26 out of 225 (11.6%) AIRD patients, previously diagnosed with COVID-19 during RTX treatment period, developed 27 prCOVID-19 events (females: 20 (76.9%), median age: 61 years, median disease duration: 5.5 years, ≥3 COVID-19 vaccine doses: 20 (76.9%)). No prCOVID-19 infection in a control sample of 661 patients treated with other biologic/targeted synthetic/conventional synthetic disease-modifying antirheumatic drugs was documented. Median cumulative RTX dose was 12 g, while in 17 (68%) prCOVID-19 events, IgG levels were below 700 mg/L. Median duration of prCOVID-19 infection was 65 (IQR 74) days and median duration of hospitalisation 10.5 (IQR 14) days. 11 patients (42.3%) had ≥2 hospitalisations, 3 patients needed mechanical ventilation and 4 deaths were recorded. 59 of 113 (52.2%) nasopharyngeal PCR samples (NPS) and 12/17 (70.6%) bronchoalveolar lavage (BAL) PCR samples were positive during prCOVID-19. Bronchoscopy established the diagnosis of prCOVID-19 in 33% of events.

Conclusion: AIRD patients treated with RTX are at risk for prCOVID-19. In such patients, the diagnostic accuracy of NPS PCR is suboptimal, necessitating PCR testing in BAL when prCOVID-19 is highly suspected.

Keywords: COVID-19; Infections; Rituximab.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1. Swimmer plot of disease course. Deaths are denoted with an ‘x’. BAL, bronchoalveolar lavage; NPS, nasopharyngeal; prCOVID-19, persistent or relapsing COVID-19.
See this image and copyright information in PMC

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