(1173) Unraveling the Mysteries of Chronic COVID-19

Introduction: Guidelines for treating COVID-19 infection have been changing at an unprecedented pace since the beginning of the pandemic. Persistent COVID-19 infection is an increasingly established entity, mainly in immunocompromised patients, including recipients of immunosuppressive therapy such as B cell-depleting anti-CD20 treatment. The diagnosis is challenging, as its symptoms overlap with post-acute sequelae of SARS-CoV-2 (PASC).

Description: A 62-year-old female, wildlife center volunteer, with anti-myelin-associated-glycoprotein neuropathy, responsive to rituximab presented in late February 2023 with fever, and fatigue. Subsequently, she tested positive for COVID-19. She was not treated with antiviral therapy and only received symptomatic care. Although her symptoms initially improved, she experienced another episode of fever and fatigue. Despite negative nasopharyngeal COVID-19 PCR results, chest imaging revealed multifocal bilateral ground-glass opacities. Notably, antibiotic trials with doxycycline and amoxicillin-clavulanate were ineffective. Given findings concerning potential hypersensitivity pneumonitis and Pneumocystis jirovecii pneumonia, the patient underwent bronchoalveolar lavage (BAL) and was empirically started on sulfamethoxazole and trimethoprim (TMP-SMX). Unfortunately, the patient's symptoms persisted despite 21 days of TMP-SMX. Ultimately, the diagnosis was established when a repeat BAL tested positive for COVID-19. The patient exhibited remarkable improvement following a course of ritonavir-boosted nirmatrelvir treatment. This case highlights the importance of recognizing the clinical entity of persistent COVID-19, particularly in immunocompromised individuals on B cell-depleting therapy, who may be unable to spontaneously eliminate the infection.

Discussion: Persistent COVID-19 is an emerging entity with constant evolution in diagnosis and treatment. Studies have established association of persistent COVID-19 with low B- cells or hypogammaglobulinemia. This is the first case report where ritonavir-boosted nirmatrelvir was used for the treatment of persistent COVID-19. Further trials are warranted to explore the efficacy of ritonavir-boosted nirmatrelvir treatment for patients experiencing persistent COVID-19 symptoms.