Successful recovery of a patient with multiple myeloma from severe coronavirus disease 2019 (COVID‑19) pneumonia during the first chemotherapy cycle: A case report

  • Authors:
    • Ziping Li
    • Yan Chen
    • Bohan Yang
    • Haiping Song
    • Wanxin Chen
    • Hao Zhou
  • View Affiliations

  • Published online on: February 24, 2021     https://doi.org/10.3892/etm.2021.9823
  • Article Number: 392
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Abstract

A continuing outbreak of pneumonia associated with the 2019 novel coronavirus (2019‑nCoV) was initially described in Wuhan, China in December 2019. Weak and elderly individuals, and those with chronic diseases such as hematological malignancies are prone to develop severe pneumonia. The humoral immunity of patients with multiple myeloma is prevalently low, and their inferior immunity further deteriorates during chemotherapy. For patients with onco‑hematological malignancies infected with 2019‑nCoV during the first chemotherapy cycle, the clinical treatment experience is lacking. The present study is a report of a 61‑year‑old patient newly diagnosed with multiple myeloma in the key 2019‑nCoV outbreak area, who suffered severe 2019‑nCoV pneumonia during the first chemotherapy cycle. The present case report demonstrated that a rapidly progressive and severe form of pneumonia was a specific clinical feature of COVID‑19, especially in immunocompromised patients with cancer. The treatment strategy combining timely suspending chemotherapy, early intervention using intravenous immunoglobulin, interferon α inhalation and oral antiviral drugs was effective. Therefore, in the pandemic environment, it is strongly recommend that the risk of 2019‑nCoV infection is assessed prior to chemotherapy.

Introduction

A continuing outbreak of pneumonia associated with a novel coronavirus was initially described in Wuhan, China in December 2019(1). On 11 February 2020, the International Committee on Taxonomy of Viruses named the new coronavirus ‘severe acute respiratory syndrome-related coronavirus 2’ or SARS-CoV-2, whilst the World Health Organization named the disease coronavirus disease 2019 or COVID-19(1). The most common symptoms of COVID-19 are fever, dry cough and shortness of breath (2). However, some patients present other symptoms similar to influenza or no obvious symptom of disease onset (2). Patients who had serious underlying illness and elderly individuals, particularly those with hematological malignancies, are at a high risk of developing severe pneumonia (1). Multiple myeloma (MM) is the second most common hematological cancer accounts for ~1% of neoplastic diseases and 13% of hematologic cancers, which results from the accumulation of malignant plasma cells in the bone marrow (3). Developed countries are reported to have much higher MM incidence and prevalence compared with those in developing countries (4,5). Three high-incidence areas around the world are North America, Australia and Western Europe, with incidences ranging from 3 to 6 per 100,000 person-years, where the 5-year prevalence range from 7 to 14 per 100,000 population (4,5). The humoral immunity of patients with multiple myeloma is prevalently low, and their inferior immunity further deteriorates during chemotherapy (6). For immunocompromised patient with cancer infected with 2019-nCoV during the first chemotherapy cycle, the treatment experience is lacking. In the front line facing 2019-nCoV, the present study is the first report outlining the clinical features and the treatment process of a severe pneumonia in a 2019-nCoV-infected patient with multiple myeloma undergoing the first chemotherapy cycle.

Case Report

On 8 January 2020, a 61-year-old male, who suffered from chest pain for several months, was admitted to Wuhan Union Hospital without symptoms of fever or cough. The patient denied having ever been to the Huanan Seafood Wholesale Market, which was the key spot of the 2019-nCoV outbreak and was a 10-min ride away from the hospital. The patient subsequently underwent bone marrow aspiration.

On 15 January 2020 (day 1), the patient was admitted to the Department of Hematology and was diagnosed with multiple myeloma IgG-κ (Durie-Salmon Stage II A) (7). The computed tomography (CT) of the chest was normal on day 1 (Fig. 1A). Considering the patient's status, chemotherapy, including bortezomib (1.3 mg/m2, planned for days 2, 5, 9 and 12) and dexamethasone (40 mg, planned for days 2, 5, 9 and 12) was prescribed. The patient did not feel any notable discomfort after the therapy commenced on 16 January 2020.

On 21 January 2020 (day 7), the patient developed a fever of 38.5˚C. Chemotherapy (bortezomib and dexamethasone, day 8 and day 11, intravenous infusion) was suspended. Ceftazidime (2.4 g per time, twice daily for 3 days, intravenous infusion) was administered the following day. However, the patient suddenly exhibited dyspnea, and capillary oxygen saturation (SpO2) was 80% while breathing ambient air on the night of 24 January 2020. After inhaling oxygen via a face mask at 10 l/min, the SpO2 of the patient reached 95%. Intravenous immunoglobulin was administered, and the antibiotics were upgraded to Meropenem (0.1 g per time, three times a day for 5 days, intravenous infusion) combined with Teicoplanin (400 mg per time, once daily for 5 days, intravenous infusion), combining antiviral Ganciclovir (300 mg per time, twice daily for 5 days, intravenous infusion) and antifungal Voriconazole (0.2 g per time, twice daily for 5 days, intravenous infusion) therapy (Fig. 2). Although no fever (≥38˚C) was observed after 27 January 2020, the symptoms of cough and dyspnea were progressing.

On 28 January 2020 (day 14), the pharyngeal swab nucleic acid test of 2019-nCoV was determined positive by reverse transcription-quantitative PCR. Since the chest CT on 23 January 2020 revealed multiple ground glass opacities in both lungs (Fig. 1B), according to the diagnostic criteria of COVID-19 Diagnosis and Treatment Plan (Trial Fifth Edition) issued by the National Health Commission of China, the patient was diagnosed with severe COVID-19 pneumonia (8). The patient was transferred to the Department of Infection, and the antiviral and antifungal therapy were ceased on 29 January 2020; IFN-α inhalation (5 MU per time, twice daily) was administered (Fig. 2). However, symptoms such as cough and bloody sputum gradually progressed. The routine blood tests revealed a gradually decrease in lymphocytes (Table I). The chest CT on 31 January 2020 (day 17) demonstrated a progression of pneumonia (Fig. 1C).

Table I

Clinical laboratory blood test results.

Table I

Clinical laboratory blood test results.

MeasureReference rangeDay 1Day 6Day 9Day 13Day 17Day 19Day 24Day 27Day 31Day 40
White cell count, cells x109/l3.5-9.55.215.877.79NA6.566.337.176.54NA7.55
Hemoglobin, g/l130-17510610799NA93918182NA85
Platelet count, cells x109/l125-350227141163NA292NA390394NA314
Neutrophils, %40-7566.086.287.2NA83.883.381.475.9NA72.4
Lymphocytes, %20-5026.512.311.8NA14.313.914.617.8NA17.2
Neutrophil count, cells x109/l1.8-6.33.445.066.79NA5.505.275.844.96NA5.47
Lymphocyte count, cells x109/l1.1-3.21.380.720.92NA0.940.881.041.17NA1.30
D-dimer, mg/l FE<0.50.360.660.56NANANA0.36NANANA
Fibrinogen, g/l2.0-4.03.955.556.17NANANA6.25NANA4.95
Alanine aminotransferase, U/l21-72312523331378391825230
Albumin, g/l35-5033.525.624.725.026.220.616.820.725.830.1
Globulin, g/l23-3264.764.860.159.464.870.271.370.267.657.0
Creatinine, μmol/l58.0-110.080.775.269.860.355.951.053.055.455.952.5
Creatine kinase, U/l38-17460NANANA27NA2430NA47
Lactate dehydrogenase, U/l109-245135NANA336326NA157147157153
Procalcitonin, µg/l<0.5NANA <0.13 0.31<0.13 0.07 0.70 3.80NA 0.40
C-reactive protein, mg/l <8.00NANA120.00139.0049.40108.78101.9946.0610.4123.57

[i] NA, not available; FE, fibrinogen equivalent.

On 1 February 2020 (day 18), the patient was transferred to the COVID-19 Isolation Ward, and the treatment was changed to arbidol (0.2 g per time, three times a day), oseltamivir (75 mg per time, twice daily), IFN-α inhalation (5 MU per time, twice daily), and moxifloxacin (0.4 g per time, once daily) (Fig. 2). The patient's condition improved gradually and slightly. The chest CT on 10 February (day 27) demonstrated a notable decrease in the lesions (Fig. 1D). Since the patient's fever had stopped for 2 weeks and the CT scan was indicating improvement, the present treatment strategy was considered to be correct. On 24 February 2020 (day 41), the patient's symptoms improved significantly, and the chest CT demonstrated increased absorption in the lung lesions (Fig. 1E). The routine blood test revealed a gradual increase in lymphocyte count, and the patient exhibited significant improvement in dyspnea, cough and bloody sputum (Table I). On 28 February 2020 (day 45), the patient was provided with a nasal catheter for oxygen inhalation and remained in hospital for further improvement.

On 8 January 2020, the serum immunoglobulin test identified an IgG level of 68.8 g/l (reference range, 7.51-15.60 g/l) and IgA level of 0.44 g/l (reference range, 0.82-4.53 g/l). The chemotherapy was suspended on 23 January 2020, and antiviral drugs were administered from 25 January 2020. On 31 January 2020, the results of the serum immunoglobulin test demonstrated an IgG level of 56.2 g/l and an IgA level of 0.35 g/l. The level of IgG and IgA was lower compared with that prior to the antiviral treatment.

Discussion

The effective clinical recovery of the patient in the present study revealed that timely suspension of chemotherapy was necessary, and early treatment using intravenous immunoglobulin combined with aerosol inhalation of IFN-α and two oral antiviral drugs arbidol and oseltamivir was beneficial. The patient was administered both antibiotic and antiviral drugs in the initial phase of treatment for several reasons. Firstly, the respiratory defense mechanism can be severely damaged and the ability of the immune system to identify and clear the virus can be inhibited during influenza virus infection (9,10). Secondly, protein kinases produced by Streptococcus pneumoniae and Staphylococcus aureus promote the spread of influenza virus (11). Lastly, atypical pathogens may cause opportunistic infections due to the hypoimmunity of the patient.

Considering the time consistency of CT images and pulmonary symptoms, a previous study argued that the CT manifestations were lagging behind the clinical symptoms (12). In the present case, when the patient's 2019-nCoV nucleic acid tests were negative twice and his symptoms had notably improved, the chest CT image still indicated no significant improvement.

Of note, another patient (56-year old female) with multiple myeloma in complete remission in the same ward was not infected. Furthermore, the infected patient's close contacts (accompanying family members) were not infected. It was observed that immunocompromised patients were much more susceptible and, thus, it may be speculated that hypoimmunity is an important risk factor in 2019-nCoV infection and progression.

Zhang et al (13) previously showed that tocilizumab is effective in the treatment of COVID-19 in MM with obvious clinical recovery. Compared with data from the present study, the study by Zhang et al (13) indicated that excessive immune response and a strong cytokine storm are activated in severe COVID-19, rendering immunotherapy to be an appropriate treatment for COVID-19 patients with hematologic malignancies (14). Compared with a reported case of a patient with Middle East respiratory syndrome (MERS), who also had multiple myeloma (15), it was observed that the patient with COVID-19 recovered successfully using the current treatment strategy. One patient with multiple myeloma in remission (non-chemotherapy period) infected with MERS-CoV died after intensive antimicrobial treatment with meropenem, levofloxacin, vancomycin, caspofungin, aciclovir and oseltamivir (15). This case of MERS suggests that since the immune function of the MM patient was compromised, which represents a high risk for virus infection, the MM patient with MERS in remission died even after intensive antimicrobial treatment. It also appears that the lethality of 2019-nCoV is lower compared with that of MERS-CoV, which needs further investigation. However, no previous reports of severe acute respiratory syndrome infection in patients with multiple myeloma are currently available.

It has been reported that IFN-α treatment prolongs remission in patients with multiple myeloma; response rates of 20% were achieved when IFN-α (between 4.8 and 18.7 MU/week) was applied as single-agent treatment for multiple myeloma (16). For COVID-19 treatment in the present study, IFN-α was administered by aerosol inhalation (5 MU, twice daily). It is postulated that this treatment strategy may coincidentally and synergistically help to control multiple myeloma.

Of note, a single case in determining a treatment strategy for a diverse population has limitations. Owing to a lack of sufficient knowledge about the new infection, the management of COVID-19 in the hematological malignancy population remains unclear. According a previous report, comorbidities increase the risk of severe pneumonia in patients with COVID-19(17), although history of hematological malignancies has not been reported as a risk factor. Despite the limitations of single-case observations, the presentation pattern and resolution of the disease using the described measures in the present case may serve to inform the treatment if such patients are encountered elsewhere. Further large-scale epidemiologic studies are needed to analyze the potential treatment strategies in patients with hematological malignancies infected with 2019-nCoV.

In conclusion, the present report describes for the first time the clinical features and treatment process of severe 2019-nCoV pneumonia in a patient with cancer undergoing the first chemotherapy cycle. The patient achieved a notable improvement. The present case highlights that a rapidly progressive and severe form of pneumonia is a specific clinical feature of COVID-19, particularly in immunocompromised patients. The treatment strategy in the present report, which included timely suspension of chemotherapy and early administration of intravenous immunoglobulin combined with IFN-α inhalation and oral antiviral drugs, was demonstrated to be effective. Therefore, in the pandemic environment, it is strongly recommended that the risk of 2019-nCoV infection is assessed prior to chemotherapy.

Acknowledgements

Not applicable.

Funding

Funding: This study was supported by the Clinical Innovation Funds of Union Hospital (grant no. 02.03.2019-125).

Availability of data and materials

The data generated and/or analyzed during the current study are not publicly available due to protection of patient privacy but are available from the corresponding author on reasonable request.

Authors' contributions

ZL and YC were major contributors in acquiring data and writing the manuscript. BY and HS helped with data collection and contributed to the critical revision of the manuscript for important content. BY and HS confirmed the authenticity of all the raw data and given constructive suggestions. HZ and WC designed the study and revised the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Written informed consent was obtained from the patient.

Patient consent for publication

The patient gave consent for the lung images to be published in this article.

Competing interests

The authors declare that they have no competing interests.

References

1 

Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, et al: China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 382:1708–1720. 2020. View Article : Google Scholar

2 

Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ and Prescott HC: Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review. JAMA. 324:782–793. 2020.PubMed/NCBI View Article : Google Scholar

3 

Kazandjian D: Multiple myeloma epidemiology and survival: A unique malignancy. Semin Oncol. 43:676–681. 2016.PubMed/NCBI View Article : Google Scholar

4 

Cowan AJ, Allen C, Barac A, Basaleem H, Bensenor I, Curado MP, Foreman K, Gupta R, Harvey J, Hosgood HD, et al: Global Burden of Multiple Myeloma: A Systematic Analysis for the Global Burden of Disease Study 2016. JAMA Oncol. 4:1221–1227. 2018.PubMed/NCBI View Article : Google Scholar

5 

Teras LR, DeSantis CE, Cerhan JR, Morton LM, Jemal A and Flowers CR: 2016 US lymphoid malignancy statistics by World Health Organization subtypes. CA Cancer J Clin. 66:443–459. 2016.PubMed/NCBI View Article : Google Scholar

6 

Palumbo A, Chanan-Khan A, Weisel K, Nooka AK, Masszi T, Beksac M, Spicka I, Hungria V, Munder M, Mateos MV, et al: CASTOR Investigators: Daratumumab, Bortezomib, and Dexamethasone for Multiple Myeloma. N Engl J Med. 375:754–766. 2016.PubMed/NCBI View Article : Google Scholar

7 

Durie BG and Salmon SE: A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer. 36:842–854. 1975.PubMed/NCBI View Article : Google Scholar

8 

National Health Commission of People's Republic of China: Diagnosis and treatment of pneumonia caused by novel coronavirus (trial fifth edition). http://www.nhc.gov.cn/jkj/s3577/202002/a5d6f7b8c48c451c87dba14889b30147/files/3514cb996ae24e2faf65953b4ecd0df4.pdf. Accessed February 2, 2020 (In Chinese).

9 

Mina MJ and Klugman KP: The role of influenza in the severity and transmission of respiratory bacterial disease. Lancet Respir Med. 2:750–763. 2014.PubMed/NCBI View Article : Google Scholar

10 

Herold S, Becker C, Ridge KM and Budinger GR: Influenza virus-induced lung injury: Pathogenesis and implications for treatment. Eur Respir J. 45:1463–1478. 2015.PubMed/NCBI View Article : Google Scholar

11 

Chertow DS and Memoli MJ: Bacterial coinfection in influenza: A grand rounds review. JAMA. 309:275–282. 2013.PubMed/NCBI View Article : Google Scholar

12 

Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, Fan Y and Zheng C: Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study. Lancet Infect Dis. 20:425–434. 2020.PubMed/NCBI View Article : Google Scholar

13 

Zhang X, Song K, Tong F, Fei M, Guo H, Lu Z, Wang J and Zheng C: First case of COVID-19 in a patient with multiple myeloma successfully treated with tocilizumab. Blood Adv. 4:1307–1310. 2020.PubMed/NCBI View Article : Google Scholar

14 

Zhou Y, Fu B, Zheng X, Wang D, Zhao C, Qi Y, Sun R, Tian Z, Xu X and Wei H: Pathogenic T-cells and inflammatory monocytes incite inflammatory storms in severe COVID-19 patients. Natl Sci Rev. 7:998–1002. 2020. View Article : Google Scholar

15 

Drosten C, Seilmaier M, Corman VM, Hartmann W, Scheible G, Sack S, Guggemos W, Kallies R, Muth D, Junglen S, et al: Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection. Lancet Infect Dis. 13:745–751. 2013.PubMed/NCBI View Article : Google Scholar

16 

Rasche L, Weinhold N, Morgan GJ, van Rhee F and Davies FE: Immunologic approaches for the treatment of multiple myeloma. Cancer Treat Rev. 55:190–199. 2017.PubMed/NCBI View Article : Google Scholar

17 

Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Li C, Ai Q, Lu W, Liang H, et al: Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol. 21:335–337. 2020.PubMed/NCBI View Article : Google Scholar

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Spandidos Publications style
Li Z, Chen Y, Yang B, Song H, Chen W and Zhou H: Successful recovery of a patient with multiple myeloma from severe coronavirus disease 2019 (COVID‑19) pneumonia during the first chemotherapy cycle: A case report. Exp Ther Med 21: 392, 2021
APA
Li, Z., Chen, Y., Yang, B., Song, H., Chen, W., & Zhou, H. (2021). Successful recovery of a patient with multiple myeloma from severe coronavirus disease 2019 (COVID‑19) pneumonia during the first chemotherapy cycle: A case report. Experimental and Therapeutic Medicine, 21, 392. https://doi.org/10.3892/etm.2021.9823
MLA
Li, Z., Chen, Y., Yang, B., Song, H., Chen, W., Zhou, H."Successful recovery of a patient with multiple myeloma from severe coronavirus disease 2019 (COVID‑19) pneumonia during the first chemotherapy cycle: A case report". Experimental and Therapeutic Medicine 21.4 (2021): 392.
Chicago
Li, Z., Chen, Y., Yang, B., Song, H., Chen, W., Zhou, H."Successful recovery of a patient with multiple myeloma from severe coronavirus disease 2019 (COVID‑19) pneumonia during the first chemotherapy cycle: A case report". Experimental and Therapeutic Medicine 21, no. 4 (2021): 392. https://doi.org/10.3892/etm.2021.9823