ABS0416 PERSISTENT-RELAPSING SARS-CoV-2 INFECTION FOLLOWING RITUXIMAB TREATMENT FOR AUTOIMMUNE RHEUMATIC DISEASES: NATURAL HISTORY AND IMPLICATIONS FOR MANAGEMENT

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Background: COVID-19 infection may persist or relapse in rheumatic patients under treatment with rituximab (RTX), leading to persistent detection by PCR of SARS-CoV-2 virus for protracted periods [1]. Objectives: To examine the rates and outcomes of persistent-relapsing COVID-19 (prCOVID-19) infection in patients with autoimmune rheumatic diseases who were treated with RTX. Methods: Single-center, retrospective cohort study at Attikon General University Hospital of Athens (June 2021 - September 2024). We included all patients from the Clinical Immunology-Rheumatology Unit treated with RTX who were diagnosed with prCOVID-19. PrCOVID-19 infection was defined as persistence of symptoms for >30 days with pulmonary infiltrates and persistently positive or PCR-based conversion in respiratory samples [1, 2]. Results: 22 out of 450 (4.9%) patients, developed persistent COVID-19 infection. Of note, no prCOVID-19 infections were documented in patients on biologic or targeted DMARDs within the same period. Patient baseline characteristics are presented in Table 1. The most frequent diagnoses were SLE (n=5), dermatomyositis (n=3), ANCA vasculitis (n=8), rheumatoid arthritis (n=6). Of note, twelve (12) patients (54.5%) had lung involvement associated with their rheumatic disease. Median disease duration was 5.5 (IQR 4.6) years. Median cumulative RTX dose was 13g (IQR 6.5, min 6g), while 54.5% of patients had low (<700mg/L) IgG levels (median 570mg/L, IQR 345). Median time from last RTX was 3 (IQR 4, max 11.4) months, while 7/18 patients received IVIG replacement. Median time duration of COVID-19 infection was 78 (IQR 74) days and median time of hospitalization 10.5 (IQR 13.8) days. Ten patients (45.5%) had ≥2 hospitalizations, while 3 deaths (13.6%) were recorded. 53 out of 104 (51%) nasopharyngeal PCR samples (NPS) and 12/17 (70.6%) bronchoalveolar lavage (BAL) PCR samples were positive during active COVID infection, while a total of 9 BAL+/NPS- and 3 BAL-/NPS+ cases were recorded. One patient experienced persistent COVID disease twice. In Figure 1 the disease course, hospitalizations, deaths, NPS PCR and BAL PCR results are presented. Conclusion: Rheumatic patients treated with RTX are at risk for persistent/relapsing COVID-19 infection. In these patients the diagnostic accuracy of nasopharyngeal PCR is suboptimal, necessitating the use of PCR-testing in BAL, when COVID-19 infection is highly suspected. REFERENCES: [1] H. M. Machkovech et al. , "Persistent SARS-CoV-2 infection: significance and implications," Jul. 01, 2024, Elsevier Ltd . doi: 10.1016/S1473-3099(23)00815-0. [2] N. Furie et al. , "Persistent Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia in Patients Treated with Anti-CD20 Monoclonal Antibodies," Open Forum Infect Dis , vol. 10, no. 10, Oct. 2023, doi: 10.1093/ofid/ofad464. Acknowledgements: We thank Dr Boumpas for critical review. Disclosure of Interests: None declared . © The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Neither EULAR nor the publisher make any representation as to the accuracy of the content. The authors are solely responsible for the content in their abstract including accuracy of the facts, statements, results, conclusion, citing resources etc.

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