Plasma Exchange Therapy Treats Man With CAD and COVID-19
An elderly man with cold agglutinin disease (CAD) and COVID-19 was successfully treated with plasma exchange therapy and folic acid supplements.
This case highlights how plasma exchange therapy can be a rapid and temporary solution to manage and stabilize CAD, its scientists wrote.
The case report, “Cold agglutinin disease and COVID-19 requiring therapeutic plasma exchange,” was published in the journal BMJ Case Reports.
In addition to sometimes causing severe respiratory complications, COVID-19 can worsen underlying autoimmune diseases, such as CAD, with some cases being life-threatening.
Researchers described the case of a 70-year-old man with CAD who contracted COVID-19 and was successfully treated with plasma exchange therapy and folic acid supplementation.
The patient, previously diagnosed with CAD, gout, and chronic viral hepatitis B, was admitted to their hospital in Ontario, Canada, with progressive difficulty in breathing and increased levels of hemoglobin — the protein in red blood cells that is responsible for oxygen transport — in his urine.
He had tested positive for COVID-19 in a nasal swab PCR test performed one week earlier, although he was not running a fever at the time of admission. He did, however, show signs of COVID-19-related pneumonia, including hazy spots in lung computed tomography (CT) scans that bore an appearance of ground glass.
The man had an elevated heart rate and was hyperventilating, although this had not yet resulted in a low blood oxygen level.
Blood work confirmed the patient had severe and active CAD, with his hemoglobin levels rapidly falling, and his red blood cells clumping together (agglutination) due to the presence of cold agglutinins — self-reactive antibodies that bind and destroy red blood cells at low temperatures.
At this point, the man was transferred to a specialty center to receive urgent treatment for hemolytic anemia — a condition that arises when red blood cells are destroyed faster than they are made — caused by CAD.
Once there, he received plasma exchange therapy, a procedure that essentially washes plasma — the liquid portion of blood — to remove disease-causing cold agglutinins.
Because of his COVID-19, the patient could not take rituximab, a standard CAD therapy that works by lowering the levels of antibody-producing immune B-cells. Instead, he was given folic acid supplements to promote red blood cell formation, and was kept warm in an effort to prevent cold agglutinins from attaching to red blood cells.
The decision to treat the patient with dexamethasone and not rituximab had to be taken with care. Glucocorticoids like dexamethasone are not effective CAD therapies, but B-cell depletion driven by rituximab can impair the body’s ability to fight infections, such as COVID-19.
“We therefore avoided rituximab in acute treatment of decompensated [cold autoimmune hemolytic anemia] to prevent worsening of COVID-19 due to safety concerns including delay in therapeutic activity,” the scientists wrote.
Doctors monitored the man closely, both for signs of change with COVID-19 and CAD. They treated his symptoms of COVID-19-related pneumonia with daily oral dexamethasone, while hemolytic anemia required a transfusion of two units of packed red blood cells.
The man responded well to treatment, and did not require oxygen therapy. He steadily improved over the next four days before being discharged.
His follow-up plan included evaluation for either rituximab and bendamustine therapy, or enrollment in a complement inhibitor clinical trial, once he recovered from COVID-19.
“Cold agglutinin disease can be exacerbated by an acute viral infection like COVID-19,” the researchers wrote. “Therapeutic plasma exchange is a rapid temporary solution for fulminant cold autoimmune haemolysis and can stabilise a patient.”