Benign course of COVID-19 in a multiple sclerosis patient treated with Ocrelizumab.

To the editor,

Currently, the 2019 novel coronavirus disease (COVID-19) is a global public health threat. Despite the emerging high number of studies on clinical characteristics and prognosis of COVID-19, the data in the special population, including patients with multiple sclerosis (MS), is very limited. We would like to thank Novi et al. (2020) for the case report of COVID-19 in an MS patient treated with Ocrelizumab. The case report provided us more insight into the clinical course of COVID-19 in MS patients who are on immunosuppressive (anti-CD20) agents. The authors also proposed the hypothesis that the B cell depletion in MS patients who were treated with Ocrelizumab may help in preventing severe COVID-19 infection (Novi et al., 2020).

We would like to share a similar presentation of a patient who was admitted to our hospital. Our patient is a 31-year-old male with history of MS and has been receiving Ocrelizumab since 2018. His past medical history is pertinent for severe obesity with BMI of 41. In contrast to Novi et al. (2020) case, our patient recent blood tests showed only mild B-cell depletion (80 CD19+ cell/mm3).

The patient presented with dyspnea and dry cough for 5 days. He also reported nausea, vomiting, and watery diarrhea but denies any fever. His vital signs were normal. Oxygen saturation was 94%. The physical exam, including lung examination, was unremarkable. Laboratory results were as follows: white blood count 7.8×103 /mm3 with lymphocytes of 13.6%, creatinine 0.8 mg/dl, C-reactive protein 10.03 mg/dl (normal <0.4 mg/dl) and IL-6 21.1 pg/mL (normal < 15.5 pg/mL). Chest X-ray (CXR) showed bilateral ground-glass opacities. His COVID-19 PCR test was positive. He was admitted due to COVID-19 pneumonia and received hydroxychloroquine 400 mg twice daily the first day and 200 mg twice daily for the following four days. He required oxygen supplement via nasal cannula for two days. His symptoms were improved, and he was discharged on day 5 without complications.

We described the case of an MS patient with a decrease in B-cell lymphocytes due to Ocrelizumab treatment. Our patient has a slightly more severe clinical course, including a longer hospital stay and the requirement of oxygen supplement. The patient blood test also revealed significantly higher IL-6 level compare with a patient-reported in Novi et al. (2020).

These may support the Novi et al. (2020) hypothesis that B-cell depletion prevents against severe COVID-19, as the degree of B-cell suppression seemed to inversely correlate with the severity of the disease.

Host immunity response to viral pathogen is mainly mediated via T-cell lymphocytes and natural killer cells (Giovannoni et al., 2020). Thus, B-cell depletion in MS patients who are being treated with Ocrelizumab may not significantly delay the clearance of virus from the body. Kappos et al. (2019) showed patients who were treated with Ocrelizumab did not have an increased risk of severe viral illness. In contrast, the development of acute respiratory distress syndrome (ARDS) and septic shock, which are the main causes of morbidity and mortality in patients with COVID-19, may require the B-cell induced inflammatory response and cytokine storm. This might explain why MS patients treated with Ocrelizumab are more likely to have a benign course of COVID-19 infection.

Funding

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Declaration of Competing Interest

There was no conflicts of interest