Ocular Manifestations of COVID-19 in a Patient with ANCAAssociated Vasculitis Treated with Rituximab. A Case Report

The World Health Organization announced a new coronavirus pandemic on 11 March 2020. It is known that the most frequent clinical manifestation of a new coronavirus infection is lung damage with the evolution of pneumonia, as well as respiratory distress syndrome. The highest risk of severe traction and death is known to occur in the immunosuppressive group of patients. These patients include rheumatologically patients. Currently, there is no complete understanding of the pathogenesis of the development of covid-19, as well as the pathogenesis of the development of autoimmune diseases. In a pandemic, the question of how the coronavirus infection proceeds in patients on immunosuppressive therapy, in particular on anti-B cell, is relevant. In our case report presents a 69-year-old female with ANCA-associated vasculitis remission having received a B-cell-depleting therapy with rituximab (RTX), who had an ocular lesion as a clinical manifestation of Coronavirus disease 2019 (COVID-19). Two months after RTX treatment, COVID-19 was diagnosed. The patient had extrapulmonary manifestations including central nervous system involvement and ocular symptoms such as conjunctivitis, without respiratory pathology. In this clinical observation, the patient’s disease manifested itself with right-sided conjunctivitis, which is a rare manifestation as the first symptom. This article describes the features of the course and outcome of the disease, as well as, the protective effect of RTX in course of COVID-19 is discussed. A comparative analysis of cases of COVID-19 with eye damage is being carried out. This clinical observation is of great value for doctors of all specialties, especially ophthalmologists. A multidisciplinary approach is crucial to manage COVID-19. 

1. Nasonov E.L. Coronavirus disease 2019 (COVID-19): reflections from a rheumatologist. Scientific and practical rheumatology= Nauchno-prakticheskaja revmatologija. 2020;58(2):123–32 (In Russ.). DOI: 10.14412/1995-4484-2020-123-132

2. Leisman D.E., Deutschman C.S., Legrand M. Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation. Intensive Care Med. 2020 Apr 28. DOI: 10.1007/s00134-020-06059-6

3. Shi H., Han X., Jiang N., Cao Y., Alwalid O., Gu J., Fan Y., Zheng C. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020;20(4):425–434. DOI: 10.1016/S14733099(20)30086-4

4. Zhang Y., Xiao M., Zhang S., Xia P., Cao W., Jiang W., Chen H., Ding X., Zhao H., Zhang H., Wang C., Zhao J., Sun X., Tian R., Wu W., Wu D., Ma J., Chen Y., Zhang D., Xie J., Yan X., Zhou X., Liu Z., Wang J., Du B., Qin Y., Gao P., Qin X., Xu Y., Zhang W., Li T., Zhang F., Zhao Y., Li Y., Zhang S. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med. 2020;382(17):e38. DOI: 10.1056/NEJMc2007575

5. Campbell C.M., Kahwash R. Will complement inhibition be the new target in treating COVID-19 related systemic thrombosis? Circulation. 2020 Apr 9. DOI: 10.1161/ CIRCULATIONAHA.120.047419

6. Jennette J.C., Falk R.J., Bacon P.A. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 2013;65(1):1–11. DOI: 10.1002/art.37715

7. Merkel P.A., Jayne D.R., Wang C., Hillson J., Bekker P. Evaluation of the Safety and Efficacy of Avacopan, a C5a Receptor Inhibitor, in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Treated Concomitantly With Rituximab or Cyclophosphamide/Azathioprine: Protocol for a Randomized, DoubleBlind, Active-Controlled, Phase 3 Trial. JMIR Res Protoc. 2020;9(4):e16664. DOI: 10.2196/16664

8. Beketova T.V., Nasonov E.L. A decade of experience with induction and maintenance therapy with rituximab in patients with ANCA-associated systemic vasculitis. Modern rheumatology = Sovremennaja revmatologija. 2020;14(1):12–19 (In Russ.). DOI: 10.14412/1996-7012-2020-1-12-19

9. Klypa T.V., Bychinin M.V., Mandel I.A., Andreichenko S.A., Minets A.I., Kolyshkina N.A., Troitsky A.V. Clinical characteristics of patients with COVID-19 admitted to the intensive care unit. Severe predictors. Clinical practice = Klinicheskaja praktika. 2020;11(2):6–20 (In Russ.). DOI: 10.17816/clinpract34182

10. Gao Y., Li T., Han M. Diagnostic utility of clinical laboratory data determinations for patients with the severe COVID-19. J Med Virol. 2020 Mar 17. DOI: 10.1002/jmv.25770

11. Chen X., Zhao B., Qu Y., Chen Y., Xiong J., Feng Y., Men D., Huang Q., Liu Y., Yang B., Ding J., Li F. Detectable serum SARS-CoV-2 viral load (RNAaemia) is closely correlated with drastically elevated interleukin 6 (IL-6) level in critically ill COVID-19 patients. Clin Infect Dis. 2020 Apr 17. PII: ciaa449. DOI: 10.1093/cid/ciaa449

12. Liu T., Zhang J., Yang Y. The potential role of interleukin 6 in monitoring severe case of coronavirus disesase. MedRxiv. 2020 Mar 10. DOI: 10.1101/2020/03/01/20029769

13. Mao L., Jin H., Wang M., Hu Y., Chen S., He Q., Chang J., Hong C., Zhou Y., Wang D., Miao X., Li Y., Hu B. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020 Apr 10. DOI: 10.1001/jamaneurol.2020.1127

14. Marinho P.M, Marcos A.A.A, Romano A.C, Heloisa N., Rubens B. Retinal findings in patients with COVID-19. The Lancet. 2020;395(10237):1610. DOI: 10.1016/ S0140-6736(20)31014-X

15. Hoffmann M., Kleine-Weber H., Schroeder S., Krüger N., Herrler T., Erichsen S. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell. 2020;181(2):271–280.e8. DOI: 10.1016/j.cell.2020.02.052

16. Francesca C., Daniele L., Fabrizio C., Eleonora L., Licia B., Patrizia M. SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection. Ann Intern Med. 2020;173(3):242-243. DOI: 10.7326/M20-1176

17. Zhong Y., Wang K., Zhu Y., Lyu D., Yao K. COVID-19: Evidence of the Eye. Journal of Infection. 2020;81(2):е122-е123. DOI:10.1016/j.jinf.2020.05.054

18. Ping W., Fang D., Chunhua L., Qiang L., Xingguang Q., Liang L. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020. DOI: 10.1001/jamaophthalmol.2020.1291

19. Wei-Jie G., Zheng-Yi N., Yu H., Wen-Hua L., Chun-Quan O., Jian-Xing H. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020. DOI: 10.1056/NEJMoa2002032

20. Woodruff M., Ramonell R., Cashman K., Nguyen D., Ley A. Critically ill SARSCoV-2 patients display lupus-like hallmarks of extrafollicular B cell activation. medRxiv. 2020.04.29.20083717. DOI: 10.1101/2020.04.29.20083717

21. Quinti I., Lougaris V., Cinzia Milito C. A possible role for B cells in COVID-19? Lesson from patients with agammaglobulinemia. J All Clin Immunol. April 22, 2020. DOI: 10.1016/j.jaci.2020.04.013

22. Soresina A., Moratto D., Chiarini M., Paolillo C., Baresi G., Focà E., Bezzi M., Baronio B., Giacomelli M., Badolato R. Two X-linked agammaglobulinemia patients develop pneumonia as COVID-19 manifestation but recover. Pediatr Allergy Immunol. 2020 Apr 22. DOI: 10.1111/pai.13263

23. Fill L., Hadney L., Graven K., Persaud R., Hostoffer R. The Clinical Observation of a CVID Patient Infected with COVID-19 [published online ahead of print, 2020 May 5]. Ann Allergy Asthma Immunol. 2020. DOI: 10.1016/j.anai.2020.04.033

24. Montero-Escribano P., Matías-Guiu J., Gómez-Iglesias P., Porta-Etessam J., Pytel V., Matias-Guiu J.A. Anti-CD20 and Covid-19 in Multiple Sclerosis and related disorders: a case series of 60 patients from Madrid, Spain [published online ahead of print, 2020 May 7]. Mult Scler Relat Disord. 2020;102185. DOI: 10.1016/j.msard.2020.102185