Immunocomprised and suddenly have an asymptomatic Covid infection!

[keikikumu]

My husband has CLL and is in treatment (finished Obinutuzumab, now on Venetoclax). He has had two pretty severe Covid infections; first one in June 2022, second one in December 22. The second infection turned into long Covid (fatigue, daily low grade fevers) - lasting over six months now. He woke up two days ago with a higher fever and feeling "off," so took a Covid test. To our horror, it was a bright red POSITIVE...again. We were devastated, knowing what this would mean (more months of isolation and problematic symptoms). However, the fever disappeared and he feels perfectly fine again, just two days after the positive test. So...is he asymptomatic this time? We were perplexed, so had him take a second Covid test yesterday - still positive but no symptoms. Has anyone else had this experience while immunocompromised from treatment and cancer? We just don't understand why this third infection is a nothing burger! (not complaining, just wary). Will continue to test him every other day or so and see what the results are. Thanks for any input!

[AussieNeil Administrator]

With respect to your husband's good news, which I hope continues, we now know that when we have CLL, our likelihood of developing antibodies to SARS-CoV-2 increases with the number of vaccinations/boosters and I expect, COVID-19 infections.

Given it was considered that previous exposure to the 2002 SARS virus, MERS or even a cold coronavirus may have provided some protection against SARS-CoV-2 I wasn't surprised to read today that Covid-19 antibodies may give us partial immunity to SARS and MERS

Antibodies from people who have had covid-19 or been vaccinated against it may give them partial protection against most other pathogens in the coronavirus family

(Note that this is not a study of people with CLL)

newscientist.com/article/23...

Reference: MedRxiv DOI: 10.1101/2023.08.01.23293522

"In the study, Krammer and his colleagues took blood samples from 85 people in the US who had either received two or three doses of one of the mRNA-based vaccines against covid-19, had been infected with the virus SARS-CoV-2, which can cause covid-19, or both. They compared these with 15 blood samples taken from people in the two years before the pandemic reached the US.

The blood was tested for antibodies against 21 different coronaviruses, including three variants of SARS-CoV-2, the virus behind SARS, the one behind MERS and four that cause common cold-like symptoms.

The pre-pandemic blood samples generally had no antibodies that could bind to the coronaviruses tested, although some could bind to two cold-causing coronaviruses called OC43 and HKU1, as well as a virus that affects cows, which is thought to share a common ancestor with OC43.

The samples taken during the pandemic, however, had antibodies that bound to most of the 21 viruses to some degree. This suggests a level of immunity that, while it probably wouldn’t prevent infection, would protect against severe illness and death, says Krammer. People may also have some protection against coronaviruses from T-cells, the other main arm of their immune system, he says."

Neil

[keikikumu in reply to AussieNeil]

Thank you, Neil. Whatever the reason may be, we're grateful so far. We'll continue to test him and monitor results. We are aware the the more infections one has, the more antibodies one may build up. However, because cancer treatment (especially for blood cancers) lowers one's immunity so much, we are surprised that he's not having any symptoms at all in this, his third Covid infection.

[SeymourB]

keikikumu -

While on therapy, I think any infection should be immediately reported to the doctor.

I think he's been lucky so far, but given that December infection, I fear he could experience it again.

The V&O combo doesn't kill plasma B-cells that produce antibodies, but some of those do eventually die, so total IgG, IgA, and IgM may slowly drop while on therapy. An infection may temporarily increase them. But V&O does kill other B-cells that are needed to fight serious infections.

I believe that the term "asymptomatic" means "not symptomatic after testing positive." I It's less likely for them to spread if testing negative after testing positive, but I've read that it can happen for awhile - it's just not as many virus particles.

Since he did have a fever and felt off, he was indeed symptomatic at that time. He may continue to test positive without obvious symptoms.

Legal restrictions to prevent spread no longer exist in the US. If he doesn't want to spread, he should continue testing until he tests negative, and maybe continue testing a few more days for grace. There's really not been good advice on this, in my opinion. Most advice has been about legal and epidemiological advice, at specified a specific, hard and fast period, ignoring actual evidence.

Don't be surprised to see a positive after days of negative - rebounds occur no matter whether we get Paxlovid or not. It happens after about 5-10 days from first symptoms.

Given the availability of Paxlovid, this should not be a life and death issue for the vast majority of us. Those of us with additional comorbidities like high blood pressure and diabetes should be even more cautious. Best to start Paxlovid quickly in such cases to try to avoid hospitalization. In my opinion, doctors who refuse to give Paxlovid due only to CLL BTKi, BCL2, or CD20 treatments are badly misinformed. With Venetoclax, dosage can be easily decreased for the duration of Paxlovid, and there's not much evidence that pausing BTKi drugs for the duration of the Paxlovid leads to a CLL rebound.

I would add that given that while your husband was on obinutuzumab and venetoclax, he had probably the least amount of immunity he will ever experience in his life so far. Immunity doesn't come back that much while on venetoclax alone, judging by papers I've read and my own experience. Normal immunity may be barely achieved a year or more after last obinutuzumab dose, based on vaccine response studies of COVID vaccines in CLL patients.

I wish this were easier.

=seymour=

[keikikumu in reply to SeymourB]

Thank you. Yes, he has reported it to his PCP (primary care physician), his oncologist, the APRN (registered nurse) on the "Covid Hotline" at our hospital (where he ordered his Paxlovid), and also the wonderful doctor we saw recently at the "Long Covid Clinic" here at Queens Hospital in Honolulu. No one had any real new advice to offer. We're just happy being relieved that this infection didn't turn into a ghastly one as the last two infections did. I'm going to go with the theory that he developed some good antibodies having gone through it twice now and always keeping up with his vaccinations. Crossing fingers!

[Astro617]

Maybe he's having a milder case because it's a different strain coupled with a bit of immunity from previous infections. I hope his test goes to negative soon and you don't get it!

[keikikumu in reply to Astro617]

Thank you. Yes, that's a very good hypothesis. Whatever it is, we're accepting it with a lot of gratitude! His third test today (he's testing every 48 hours) was very faint; hoping the next one (in 2 days) will be a negative.