A 32-year old woman with relapsing-remitting multiple sclerosis (RRMS) presented herself in the emergency unit with fever, coughing, arthralgia and diarrhea for seven days. Multiple sclerosis (MS) was diagnosed 3 years earlier after the patient had developed paresthesia in the left leg and blurred vision. Immunosuppressive treatment with rituximab was established after diagnosis and administered every 6 months, the fifth time two month prior to hospital admission. Since the first course of rituximab no relapses or severe adverse effects occurred.
On presentation the patient was normoxemic and had moderate symptoms. Nasopharyngeal swab was performed and real-time polymerase chain reaction (rt-PCR) tested positive for SARS-CoV-2. Chest x-ray showed bilateral opacities over the lung bases. Elevated C-reactive protein (CRP) was noted (CRP 97.7 mg/L (normal: < 5)) and symptomatic therapy was administered. Since she remained normoxemic no specific antiviral or steroid therapy was administered. Subsequently, the patient was discharged the first time after 4 days with a non-severe course of COVID-19.
Because of persistent cough and fever up to 39,1°C the patient presented herself at the emergency department 15 days after symptom-onset and was admitted to the hospital once more. Rt-PCR for SARS-CoV-2 still tested positive and CRP increased to 176 mg/L. Piperacillin-Tazobactam was initiated for potential bacterial superinfection. Despite this therapy daily fever spikes continued and CRP failed to decrease. Consequently, antibiotic treatment was switched to Meropenem and Vancomycin was added 3 days afterwards but clinical improvement could not be achieved and CRP was continuously high at 200.6 mg/L.
Computed tomography (CT) of the chest (Fig. 1) and abdomen showed persistent bilateral ground glass opacities but no other focus of infection. Transthoracic echocardiogram showed no evidence for endocarditis. Multiple blood cultures and sputum culture showed negative results. In consideration of invasive fungal infections galactomannan and beta-d-glucan were performed with negative results. FACS-analysis showed complete B-cell-depletion but otherwise normal cell population.
25 days after initial symptom-onset rt-PCR tested negative on SARS-CoV-2. Neutralizing antibodies against SARS-CoV-2 were not detectable (electrochemiluminescence immunoassay “ECLIA” - Roche). In consideration of persistent clinical manifestations of Covid-19 during antibiotic application, failed evidence of other infection and non-detectable SARS-CoV-2-antibodies a treatment attempt with convalescent plasma was initiated lasting 5 days. After the third day of treatment the patient was afebrile the first time since initial symptom onset and sustained clinical recovery ensued. After therapy completion CRP decreased to 35.3 mg/L. Another chest-CT (Fig. 1) showed the bilateral opacities regressive.
Throughout the observed period of time the patient had no signs of activity regarding MS and was finally discharged from hospital 41 days after symptom-onset in good condition.