Secondary organising pneumonia to persistent SARS-CoV-2 infection in immunocompromised patient

A 62-year-old male with a history of follicular lymphoma, in complete remission under treatment with rituximab. He presented with SARS-CoV-2 infection which developed three months after primary infection with pulmonary infiltrates suggestive of organising pneumonia refractory to corticosteroid treatment (Fig. 1). It was associated with hypogammaglobulinemia secondary to anti-CD20, negative IgG-IgM SARS-COV-2 and positive PCR against SARS-COV-2 in nasopharyngeal swab specimens and bronchoalveolar lavage. Given the resistance to treatment, a cryobiopsy was performed, which confirmed the presence of organising pneumonia (Fig. 2, arrow) and also hyaline membranes, with positive immunohistochemical staining for SARS-CoV-2 in alveolar epithelium (Fig. 3, arrows).

Figure 1.

Coronal reconstruction of chest CT (lung window) with bilateral interstitial involvement and predominantly peripheral septal thickening associated with increased ground glass opacities.

Figure 2.

Lung cryobiopsy (HE 20×) showing chronic interstitial inflammation and alveolar invasion with immature collagen plugs or «Masson bodies» (arrow).

Figure 3.

Immunohistochemical staining positive for SARS-Co-V2 in hyaline membranes.

Immunocompromised patients have a higher risk of persistent viremia, which could determine treatment resistance. There are few data on histopathological findings, although the presence of organising pneumonia has been documented in biopsy samples in patients with persistent pulmonary infiltrates and diffuse alveolar damage, with antibodies against the Rp3 NP protein of SARS-COV-2 in alveolar epithelial cells of autopsy specimens. To our knowledge, the identification of SARS-COV-2 in lung tissue had not been described in living patients. The persistence of the antigenic stimulus in lung tissue could explain the resistance of the condition.