What is it about?
An 81-year-old woman with type 2 diabetes and follicular lymphoma in complete remission (after rituximab-based therapy) developed COVID-19 alongside hyperosmolar hyperglycemic syndrome (HHS). Despite prior vaccination and tixagevimab/cilgavimab (Evusheld), she showed persistent SARS-CoV-2 antigen positivity. Notably, her spike IgG (S-IgG) was high (consistent with vaccination/monoclonal antibodies), while nucleocapsid IgG (N-IgG)—which typically rises after natural infection—did not increase. She received fluids, insulin, and a 10-day remdesivir course; antigen levels fell from 30,802 COI at admission to 24 COI by day 17, and 1.0 COI after discharge, without respiratory failure.
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Why is it important?
B-cell depletion blunts infection antibodies: After anti-CD20 therapy, patients may fail to mount N-IgG, which could prolong infection and complicate diagnosis/clearance decisions. Mixed immunity picture: High S-IgG (from vaccination/Evusheld) did not prevent prolonged antigen positivity, highlighting gaps in protection for immunosuppressed patients. Diabetes risk: COVID-19 can trigger severe metabolic crises (here, HHS) and fluctuating insulin needs in older adults. Care planning: Persistent positivity raises infection-control and discharge challenges for older, functionally vulnerable patients.
Perspectives
Clinical monitoring: In B-cell–depleted patients, track quantitative antigen and both S-IgG and N-IgG; absent N-IgG rise may flag risk for prolonged disease. Therapeutic approach: Consider early antivirals (e.g., remdesivir), meticulous HHS management (rehydration + insulin), and close renal, metabolic, and functional monitoring. Vaccination & prophylaxis: Standard schedules may be insufficient after anti-CD20 therapy; explore timing relative to B-cell reconstitution, alternative prophylaxis, and revaccination strategies. Geriatric diabetes care: Simplify regimens, teach safe insulin technique, and arrange post-discharge support (cognition/vision/hand dexterity considered). Research needs: Define best vaccination timing, the role and interpretation of N-IgG as a marker of treatment resistance/prolongation, and optimal antiviral/monoclonal strategies for B-cell–depleted, older patients.
Prof Takuya Omura
National Center for Geriatrics and Gerontology
Read the Original
This page is a summary of: Prolonged COVID-19 Infection in a Patient with Complete Remission from Follicular Lymphoma with Hyperosmolar Hyperglycemic Syndrome, Geriatrics, November 2023, MDPI AG,
DOI: 10.3390/geriatrics8060110.
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