tetano
Editor, Senior Moderator
BMC Infect Dis
. 2022 Jun 13;22(1):537.
doi: 10.1186/s12879-022-07513-0.
Anti-SARS-CoV2 antibody-mediated cytokine release syndrome in a patient with acute promyelocytic leukemia
Ahmed N Hegazy[SUP] 1 2 3 [/SUP], Jan Krönke[SUP] 4 [/SUP], Stefan Angermair[SUP] 5 [/SUP], Stefan Schwartz[SUP] 4 [/SUP], Carl Weidinger[SUP] 6 7 [/SUP], Ulrich Keller[SUP] 4 [/SUP], Sascha Treskatsch[SUP] 5 [/SUP], Britta Siegmund[SUP] 6 [/SUP], Thomas Schneider[SUP] 6 [/SUP]
Affiliations
Abstract
Background: Passive immunization against SARS-CoV-2 limits viral burden and death from COVID-19; however, it poses a theoretical risk of disease exacerbation through antibody-dependent enhancement (ADE). ADE after anti-SARS-CoV2 antibody treatment has not been reported, and therefore the potential risk and promoting factors remain unknown.
Case presentation: A 75-year-old female was admitted to the emergency room with recurrent, unexplained bruises and leukocytopenia, anemia, and thrombocytopenia. Evaluation of a bone marrow biopsy established the diagnosis of an acute promyelocytic leukemia (APL). SARS-CoV-2 RT-PCR testing of nasal and throat swabs on admission was negative. During the routine SARS-CoV-2 testing of inpatients, our patient tested positive for SARS-CoV-2 on day 14 after admission without typical COVID-19 symptoms. Due to disease- and therapy-related immunosuppression and advanced age conferring a high risk of progressing to severe COVID-19, casirivimab and imdevimab were administered as a preemptive approach. The patient developed immune activation and cytokine release syndrome (CRS) occurring within four hours of preemptive anti-SARS-CoV2 antibody (casirivimab/imdevimab) infusion. Immune activation and CRS were evidenced by a rapid increase in serum cytokines (IL-6, TNFα, IL-8, IL-10), acute respiratory insufficiency, and progressive acute respiratory distress syndrome.
Discussion and conclusion: The temporal relationship between therapeutic antibody administration and the rapid laboratory, radiological, and clinical deterioration suggests that CRS was an antibody-related adverse event, potentially exacerbated by APL treatment-mediated differentiation of leukemic blasts and promyelocytes. This case highlights the need for careful assessment of life-threatening adverse events after passive SARS-CoV-2 immunization, especially in the clinical context of patients with complex immune and hematological landscapes.
Keywords: Acute promyelocytic leukemia; Antibody-dependent enhancement; Case report; Coronavirus disease 2019; Cytokine release syndrome; SARS-CoV2; Viral infection.
. 2022 Jun 13;22(1):537.
doi: 10.1186/s12879-022-07513-0.
Anti-SARS-CoV2 antibody-mediated cytokine release syndrome in a patient with acute promyelocytic leukemia
Ahmed N Hegazy[SUP] 1 2 3 [/SUP], Jan Krönke[SUP] 4 [/SUP], Stefan Angermair[SUP] 5 [/SUP], Stefan Schwartz[SUP] 4 [/SUP], Carl Weidinger[SUP] 6 7 [/SUP], Ulrich Keller[SUP] 4 [/SUP], Sascha Treskatsch[SUP] 5 [/SUP], Britta Siegmund[SUP] 6 [/SUP], Thomas Schneider[SUP] 6 [/SUP]
Affiliations
- PMID: 35692034
- DOI: 10.1186/s12879-022-07513-0
Abstract
Background: Passive immunization against SARS-CoV-2 limits viral burden and death from COVID-19; however, it poses a theoretical risk of disease exacerbation through antibody-dependent enhancement (ADE). ADE after anti-SARS-CoV2 antibody treatment has not been reported, and therefore the potential risk and promoting factors remain unknown.
Case presentation: A 75-year-old female was admitted to the emergency room with recurrent, unexplained bruises and leukocytopenia, anemia, and thrombocytopenia. Evaluation of a bone marrow biopsy established the diagnosis of an acute promyelocytic leukemia (APL). SARS-CoV-2 RT-PCR testing of nasal and throat swabs on admission was negative. During the routine SARS-CoV-2 testing of inpatients, our patient tested positive for SARS-CoV-2 on day 14 after admission without typical COVID-19 symptoms. Due to disease- and therapy-related immunosuppression and advanced age conferring a high risk of progressing to severe COVID-19, casirivimab and imdevimab were administered as a preemptive approach. The patient developed immune activation and cytokine release syndrome (CRS) occurring within four hours of preemptive anti-SARS-CoV2 antibody (casirivimab/imdevimab) infusion. Immune activation and CRS were evidenced by a rapid increase in serum cytokines (IL-6, TNFα, IL-8, IL-10), acute respiratory insufficiency, and progressive acute respiratory distress syndrome.
Discussion and conclusion: The temporal relationship between therapeutic antibody administration and the rapid laboratory, radiological, and clinical deterioration suggests that CRS was an antibody-related adverse event, potentially exacerbated by APL treatment-mediated differentiation of leukemic blasts and promyelocytes. This case highlights the need for careful assessment of life-threatening adverse events after passive SARS-CoV-2 immunization, especially in the clinical context of patients with complex immune and hematological landscapes.
Keywords: Acute promyelocytic leukemia; Antibody-dependent enhancement; Case report; Coronavirus disease 2019; Cytokine release syndrome; SARS-CoV2; Viral infection.