CASE PRESENTATION
Here we describe a case of a SARS-CoV-2 positive patient with chronic lymphocytic leukaemia (CLL) and other comorbidities. Although was efficaciously treated, and IgG seroconverted, the patient remains SARS-CoV-2 positive two months after the disappearance of the symptoms. Moreover, the strong leucocytosis observed before the infection is dramatically reduced so that the leukocyte count is, to date, stably within the reference range. We had the opportunity to follow the time-course of biochemical, haematological, and coagulative indexes before, during and after the infection. On February 26, 2020, a 64-years-old man with a clinical history of chronic monoclonal B lymphocytes lymphocytic leukaemia (immunophenotype CD19+, CD5+, CD22+, CD23+, CD103 neg, FMC7 neg), type II diabetes, high blood pressure and vertebral instability was admitted at the Regional Hospital “San Salvatore” of L’Aquila, Italy for the acute exacerbation of the lumbosacral pain. The patient refers nausea, body temperature above 38°C, dysuria, and strangury. At admission, the haematological parameters were coherent with his previously diagnosed CLL: leukocytes were 18.33×103/µL with lymphocytes and neutrophils representing 56.5% and 40.1% of total white blood cell count, respectively. The most relevant biochemical parameters included glycemia (145 mg/dL) coherent with type II diabetes, and C-reactive Protein (CRP) which was significantly elevated (18.73 mg/dL) as well as the erythrocyte sedimentation rate (120 mm/h). Other clinical parameters including estimated glomerular filtration rate, serum electrolytes, cardiac, muscle, pancreatic and liver enzymes were normal, except for gamma-glutamyltransferase which was slightly elevated (72 UI/L). Coagulative indexes and plasma brain natriuretic peptide were normal.
The NMR of the lumbosacral rachis was compatible with a suspected spondylodiscitis, although the microbiological analysis of the biopsied sample obtained from the L4-L5 intervertebral disc was negative as well as, urine, blood, and faeces. Chest X-rays did not show alterations of lungs. The patient was treated with levofloxacin (750 mg) and teicoplanin (400 mg) once a day for 4 weeks, pregabalin 75 mg, oxycodone/naloxone 5/2.5 mg and tramadol/paracetamol 37.5/325 mg were orally administered once a day for pain relief, metformin 500 mg twice a day for glycaemic control, and the ACE2 inhibitor ramipril 2.5 mg for hypertension. The patient was moved from the Internal Medicine ward to the Long-term care ward the 10th of March with CRP 0.7 mg/dL and unaltered haematological parameters. The 18th of March, following possible exposure to a symptomatic COVID-19 positive roommate, the patient was found COVID-19 at real time RT-PCR assay and immediately transferred to Infectious Disease ward. The real time RT-PCR assay of the nasopharyngeal swab resulted positive to SARS-CoV-2 with no related symptoms although CRP immediately increased to 4.32 mg/dL and leukocytes count dropped to 5.79×103/µL. The 23rd of March arterial oxygen saturation (SaO2) was around 90% and CT scan of the chest showed bilateral ground-glass opacities, prevalently peripheric, compatible with new coronavirus infection. CRP and ferritin rapidly increased to reach the maximum 3 days after, 11.89 mg/dL and 1695.6 mg/dL, respectively. The increase of the inflammatory markers was anticipated by marked reduction in leukocytes and lymphocytes counts, whose values were perfectly within the reference ranges during the infection; the inverted leukocyte formula (neutrophils 30.6%, lymphocytes 64.8%) at the 5th of March, became normal during the active infection (neutrophils 58.5%, lymphocytes 37.2%) (figure 1).
He was successfully treated with darunavir (800 mg), ritonavir (100 mg) once a day and hydroxychloroquine (200 mg) twice per day for one week. CRP and ferritin return within the reference ranges and no other biochemical alterations were observed. To date, three months after COVID-19 infection, the patient is still positive to real time RT-PCR assay. He is completely asymptomatic and biochemical and coagulative indexes, as well as arterial blood gas test, are within the reference ranges. The patient developed humoral immunity with a strong anti-SARS-CoV2 IgG response, but not IgM, presumably due to the low titre at the time of the analysis executed 45 days after the COVID-19 diagnoses. However, negativity to IgM has been described in recent study, suggesting the possibility of a uncomplete seroconversion in CLL patients 4
Mean haematological parameters calculated in the last two months are, despite the previously diagnosed CLL, characterized by normal leukocytes count (8.64±0.36×103/µL), normal neutrophils count (3.09±0.20×103/µL) and a moderate lymphocytosis (5.02±0.46×103/µL), resulting in an inverted leukocyte formula (neutrophils 58.13±3.08%, lymphocytes 35.86±3.10%).