Therapeutic dilemmas in the management of a patient with long-term rheumatoid arthritis and severe clinical presentation of SARS-COV-2 infection

Introduction. The objective of this case report is to present a clinical course of SARS-CoV-2 infection in a patient with long-term rheumatoid arthritis and concomitant rituximab therapy. Case outline. A 58-year-old female patient was diagnosed with seropositive rheumatoid arthritis at the age of 35. She was primarily prescribed chloroquine and glucocorticoid, afterwards methotrexate and biological agent - etanercept. Because of a secondary loss of response etanercept was switched to rituximab. She had 13 cycles of rituximab and the last was given on June 2020. In December 2020 she was hospitalized due to bilateral pneumonia and respiratory insufficiency. The results of the laboratory analysis revealed anemia, leukocytosis, thrombocytosis and markedly elevated C-reactive protein, procalcitonin, D-dimer, transaminases. The findings of the chest CT scan were consistent with COVID-19 pneumonia features with accompanying bilateral pleural effusion. The patient was treated with antibiotics, corticosteroids, tocilizumab, hepatoprotective, gastroprotective, oxygen therapy and parenteral anticoagulant. Three months after recovering from pneumonia, she developed arthritis flare, hence a JAK inhibitor, baricitinib, was started. Low disease activity was achieved with baricitinib monotherapy. Conclusion. Due to a risk of a severe COVID-19, a caution may be required when applying immunosuppressive therapy in patients with rheumatic diseases.