COVID-19-Linked Pancytopenia Case Described

Author: By Lynda Williams, Senior medwireNews Reporter 

medwireNews: French clinicians have linked SARS-CoV-2 infection to the development of pancytopenia in a mantle cell lymphoma patient who had previously been successfully treated with an autologous bone marrow transplant. 

The 53-year-old man required intensive care for acute respiratory distress, pancytopenia and cytokine release syndrome 3 weeks after developing initial COVID-19 symptoms of fever, cough and dyspnoea, as well as anosmia and ageusia. 

The patient had achieved remission in 2018 and had received nine monthly maintenance treatments of anti-CD20 antibody, the last of which was given 42 days before COVID-19 symptoms, report Nahéma Issa, from Hôpital Saint-André in Bordeaux, and co-authors in a letter to the Annals of Oncology. 

Blood tests revealed the man had a haemoglobin level of 7.9 g/dL, a leukocyte count of 0.8 G/L and a platelet count of 48.0 G/L. Moreover, circulating leukocyte analysis showed a low T-cell count (0.447 G/L) and complete absence of B-lymphocytes, which the researchers attribute to the anti-CD20 therapy.  

The patient’s inflammatory markers were elevated, with a C-reactive protein concentration of 235 mg/L, a fibrinogen level above 10 g/L, a ferritin value of 8106 ng/mL and a D-dimer level of 1132 ng/mL. And his gammaglobulin level had decreased to 3.0 g/L from 4.9 g/L 6 months earlier. 

Although the patient tested negative for SARS-CoV-2 in his nasopharyngeal swab, the virus was present in bronchoalveolar lavage fluid, blood and bone marrow aspiration samples. Computed tomography showed “bilateral patchy ground-glass opacities”, the authors say. 

The patient underwent two infusions of tocilizumab 8 mg/kg and polyvalent immunoglobulins 400 mg/kg and required noninvasive ventilation and oxygen for a week.  

After 2 weeks, the patient was free from fever, had normal inflammatory biomarker levels and had reduced his oxygen requirements, but on day 45 he continued to test positive for SARS-CoV-2 in his blood and bone marrow. The patient did not produce antiviral immunoglobulin G antibodies and the pancytopenia persists, the clinicians say. 

“SARS-CoV-2 RT-PCR should be performed in blood and bone marrow aspiration in case of pancytopenia associated with typical COVID-19 especially in case of secondary humoral immunodeficiency”, Nahéma Issa et al recommend to other clinicians.

“Among the many therapeutic options under investigation, including antiviral drugs, we suggest that convalescent plasma could be useful in patients with COVID-19 infection and concurrent persistent B-cell immunodeficiency; we will consider this approach for our patient”, they conclude. 

Reference 

Issa N, Lacassin F, Camou F. First case of persistent pancytopenia associated with SARS-CoV-2 bone marrow infiltration in an immunocompromised patient. Ann Oncol; Advance online publication 29 June 2020. doi: 10.1016/j.annonc.2020.06.016