P107 Persistent SARS-COV-2 pneumonia in an immunosuppressed rheumatoid arthritis patient: a diagnostic challenge

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Abstract Introduction Patients with rheumatoid arthritis (RA) receiving long-term immunosuppressive therapy, such as methotrexate, rituximab, and corticosteroids, are at increased risk of severe respiratory infections and opportunistic pathogens. Persistent COVID-19 has emerged as a significant concern in immunosuppressed populations, further complicating the management of rheumatological conditions like RA. This case highlights the importance of a multidisciplinary approach to diagnosing and managing prolonged COVID-19 and opportunistic infections in RA patients undergoing chronic immunosuppression. Case description We present a 61-year-old woman with seropositive RA who was receiving long-term rituximab and methotrexate therapy. She developed fever, pleuritic chest pain, and progressive dyspnoea beginning in August 2023, a few months after her last rituximab infusion. Her COVID-19 test was positive, and chest imaging revealed left basal consolidation and bilateral ground-glass opacities. Despite multiple hospitalizations, a 5-day course of nirmatrelvir/ritonavir, and antibiotic treatments, her symptoms persisted, and inflammatory markers remained elevated (WBC 11.84 × 109/L, CRP 70 mg/L). Bronchoalveolar lavage (BAL) identified Pneumocystis jirovecii pneumonia (PJP), and she was treated with high-dose co-trimoxazole. A follow-up BAL in January 2024 showed PJP clearance, but her symptoms persisted with negative cultures for bacteria and mycobacteria. A repeat CT scan revealed progressive ground-glass opacities. She was started on prednisone (40 mg) for an RA flare, but her condition did not improve. A multidisciplinary review identified persistent, indeterminate SARS-CoV-2 positivity for over 62 days. Sequencing confirmed SARS-CoV-2 lineage JM.1, indicating that the infection had persisted from August to December 2023. Given the persistence of symptoms, positive SARS-CoV-2 results, and CT findings of organizing pneumonia, she was started on a 10-day course of nirmatrelvir/ritonavir. The patient showed significant clinical and radiological improvement, and her breathlessness resolved. Her RA treatment was modified to include abatacept. Discussion This case highlights the complex interaction between persistent COVID-19 and opportunistic infections in immunosuppressed RA patients. The overlapping clinical features of COVID-19 and PJP can complicate diagnosis, emphasizing the need for a multidisciplinary approach. Persistent SARS-CoV-2 infection should be considered in such patients, particularly those with CD20 depletion (e.g., rituximab), a key predisposing factor. Early antiviral therapy, including a prolonged course of nirmatrelvir/ritonavir, though not licensed for this use, may improve outcomes, as seen in our case where it was used as part of standard management for chronic COVID. We recommend that patients receive COVID-19 vaccination several weeks prior to starting rituximab therapy. Clinicians must remain vigilant for atypical pathogens and adopt a systematic approach to differentiate between infectious and inflammatory processes in immunosuppressed patients Key learning points 1. Persistent COVID-19 should be considered in immunosuppressed patients, particularly those on rituximab, presenting with ongoing respiratory symptoms that exceed the expected clinical course. 2. Pneumocystis jirovecii pneumonia (PJP) can coexist with or mimic COVID-19, and should be investigated in patients with compatible symptoms and risk factors. 3.Viral sequencing can help differentiate between persistent infection and reinfection in cases of prolonged SARS-CoV-2 positivity. 4. Extended or repeated courses of antiviral therapy, such as nirmatrelvir/ritonavir, may be effective in managing chronic COVID-19 in selected immunocompromised patients. 5. A multidisciplinary approach is essential to differentiate between infectious, inflammatory, and treatment-related complications in patients receiving chronic immunosuppression. 6. COVID-19 vaccination should be considered prior to B-cell-depleting therapies to optimise immune response.

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