Abstract
Background: Passive immunization against SARS-CoV-2 limits viral burden and death from COVID-19; however, it poses a theoretical risk of disease exacerbation through antibody-dependent enhancement (ADE). ADE after anti-SARS-CoV2 antibody treatment has not been reported, and therefore the potential risk and promoting factors remain unknown.
Case presentation: A 75-year-old female was admitted to the emergency room with recurrent, unexplained bruises and leukocytopenia, anemia, and thrombocytopenia. Evaluation of a bone marrow biopsy established the diagnosis of an acute promyelocytic leukemia (APL). SARS-CoV-2 RT-PCR testing of nasal and throat swabs on admission was negative. During the routine SARS-CoV-2 testing of inpatients, our patient tested positive for SARS-CoV-2 on day 14 after admission without typical COVID-19 symptoms. Due to disease- and therapy-related immunosuppression and advanced age conferring a high risk of progressing to severe COVID-19, casirivimab and imdevimab were administered as a preemptive approach. The patient developed immune activation and cytokine release syndrome (CRS) occurring within four hours of preemptive anti-SARS-CoV2 antibody (casirivimab/imdevimab) infusion. Immune activation and CRS were evidenced by a rapid increase in serum cytokines (IL-6, TNFα, IL-8, IL-10), acute respiratory insufficiency, and progressive acute respiratory distress syndrome.
Discussion and conclusion: The temporal relationship between therapeutic antibody administration and the rapid laboratory, radiological, and clinical deterioration suggests that CRS was an antibody-related adverse event, potentially exacerbated by APL treatment-mediated differentiation of leukemic blasts and promyelocytes. This case highlights the need for careful assessment of life-threatening adverse events after passive SARS-CoV-2 immunization, especially in the clinical context of patients with complex immune and hematological landscapes.
Keywords: Acute promyelocytic leukemia; Antibody-dependent enhancement; Case report; Coronavirus disease 2019; Cytokine release syndrome; SARS-CoV2; Viral infection.
【저자키워드】 Coronavirus disease 2019, SARS-CoV2, Antibody-dependent enhancement, Case report, Viral infection., Cytokine release syndrome, Acute promyelocytic leukemia, 【초록키워드】 passive immunization, SARS-CoV-2, Anemia, severe COVID-19, antibody, IL-6, Infection, Diagnosis, nasal, immunization, immune, Laboratory, Bone marrow, SARS-CoV-2 testing, immune activation, therapeutic, adverse event, female, Patient, death, IL-8, SARS-CoV-2 RT-PCR, IL-10, ADE, disease, COVID-19 symptoms, Admission, leukemia, antibody treatment, acute respiratory distress, CRS, administration, Clinical deterioration, high risk, Inpatients, Activation, Factor, complex, potential risk, advanced age, syndrome, life-threatening, TNFα, hematological, rapid increase, serum cytokine, viral burden, positive, throat swab, theoretical risk, Administered, approach, limit, radiological, highlight, tested, reported, exacerbated, evidenced, APL, bruise, leukemic, therapy-related immunosuppression, 【제목키워드】 Patient, leukemia,