Autologous hematopoietic stem cell transplantation with concomitant SARS-CoV-2 infection

Abstract

Coronavirus disease (COVID-19) in patients undergoing hematopoietic stem cell transplantation (HSCT) is a great concern to transplant centers around the world. While data on COVID-19 in HSCT recipients after stable engraftment is constantly growing [1–4], only limited data on the impact of COVID-19 during conditioning therapy or the pre-engraftment phase is available with only three adult cases reported as of September 2021. This data is important to help clinicians prepare for such occurrences and to put plans and strategies into place for possible COVID-19 in this highly vulnerable patient population. Therefore, we report the case of a patient with SARS-CoV-2 infection detected during conditioning chemotherapy before HSCT and review previous reports of COVID-19 in severe neutropenia shortly before/after HSCT: A 33-year-old man with relapsed testicular non-seminomatous germ-cell tumor was admitted to receive his second HSCT as part of a tandem autologous HSCT [5]. He had completed his first HSCT without any unexpected complications and had been discharged 12 days earlier. The patient was in overall good condition (ECOG performance status 0) and without any comorbidity (HCT-CI: 0 points). Upon admission, the patient had no fever or cough and a nasopharyngeal swab was negative for SARS-CoV-2 using RT-PCR technique. The start of conditioning chemotherapy was postponed due to a febrile UTI but 4 days later, after empiric antibiotic treatment and clinical improvement, myeloablative conditioning consisting of carboplatin 500 mg/m2 and etoposide 500 mg/m2 was started [5]. On ‘day minus 4’ after the patient had already completed 2 of 3 days of conditioning chemotherapy, the patient had another swab taken as part of our unit’s routine weekly RTPCR–based testing. This swab was now positive for SARSCoV-2 with a RT-PCR cycle threshold (Ct) value of 13.5 but the patient continued to be asymptomatic. Variant testing was indicative of the B.1.1.7 SARS-CoV-2 alpha variant. A BMT board decision was made to not administer the last day of conditioning chemotherapy. To protect other patients and staff, the HEPA filter positive pressure lock systems of the patient’s room was turned off for the time of required isolation. Further, an infectious disease consult recommended the use of remdesivir [6], which was started the following day for a total of 9 days and was well tolerated by the patient. A chest radiograph (CXR) showed no infiltrates or other SARS-CoV-2 specific alterations (Fig. 1A). Further, all staff and other patients admitted to our unit during this time were required to undergo RT-PCR–based SARS-CoV-2 testing the day after the patient’s initial positive test, as well as 5 days later, which were all negative. According to the initial treatment plan, a total of 3.7x106/ kg bodyweight CD34 positive autologous stem cells were administered on ‘day 0’. Over the following days during severe neutropenia, the patient continued to lack COVID-19 specific symptoms. On ‘day + 4’ the patient developed a fever and CRP values started to rise. CXR was repeated but still didn’t show any COVID-19 specific changes (Fig. 1B). Bloodand urinecultures were both positive for pseudomonas multidrug resistant gram-negative bacteria (MDRGN). Antibiotics were switched according to antibiotic susceptibility testing and fever and CRP values declined over the following days. Nasopharyngeal swabs were taken every other day and * Hanna A. Knaus [email protected]