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\begin{document}

\title{COVID-19 reinfection in Beta-Thalassemia Major Patient: first case
report.}



\author[1]{Lina Okar}%
\author[2]{Rita Ahmad}%
\author[3]{mohamed yassin}%
\affil[1]{Hamad Medical Corporation}%
\affil[2]{Affiliation not available}%
\affil[3]{HMC  NCCCR}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
All people including those with Haemoglobinopathies are at risk of
COVID-19 infection. Though those patients were considered vulnerable, a
clear prognosis, as well as the possibility of reinfection, was not
mentioned before. We report here the first case of Thalassemia beta
major who had COVID-19 reinfection detected by screening.%
\end{abstract}%



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\textbf{Introduction:}

Severe Acute Respiratory Syndrome -Coronavirus 2 (SARS-COV2) was
responsible for the latest outbreak recently, presenting as mainly
respiratory symptoms and carrying high mortality rate{[}1{]}. COVID-19
put all people at risk of being infected including haemoglobinopathies
patients. Multiple factors among those patients increase their risk for
infections yet the occurrence of reinfection and it is implication on
them, and the community were not described before. Thalassemia is one of
the most common haemoglobinopathies and requires life-long management
and follow up. Splenectomy, regular blood transfusion and iron chelation
therapy are essential components in the management plan. Unfortunately,
they cause some complications on the long term and might raise the
slurpability of current reinfection{[}2{]}. The impact of these factors
on COVID-19 infection is not well known yet.

Here we present a case of 31-year-old splenectomized lady with
transfusion dependent Beta Thalassemia Major had COVID-19 infection
recurrence detected by screening. In this article we are discussing the
possibility behind COVID-19 reinfection in thalassemia patients.

\textbf{Case presentation:}

A 31-year-old Pakistani lady with past medical history of transfusion
dependent Beta Thalassemia major, type II diabetes Mellitus and
hypothyroidism visited our hematology department for follow up and
routine blood transfusion. Due to the ongoing spread of COVID-19
infection in Qatar, PCR via nasopharyngeal swap was done as part of the
local screening plan before admission in day care for the blood
transfusion and tested positive.

The patient was admitted before due to COVID-19 infection; her previous
course was smooth without any complication as the current one. The
period between the two positive PCR was 55 days. Her current management
plan and home medications as follow: regular blood transfusion and iron
chelation therapy for thalassemia, insulin, Sitagliptin/Metformin,
levothyroxine and Tramadol. A comparison between the two presentation
was mentioned below as well the investigations results. Table.1

\textbf{Discussion:}

Coronaviruses were known before for only their mild presenting symptoms
like common cold. However, the world has recently seen a huge outbreak
caused by Sever Acute Respiratory Syndrome Coronavirus (SARS-COV2) which
was highly pathogenic and spread rapidly starting from China to all over
the world with unfortunately increased mortality rate{[}3{]}. COVID-19
presentation was categorized into typical and atypical symptoms with
fatigue, fever, dry cough and dyspnea being most common especially at
onset of the infection, while headache, sore throat, runny nose,
diarrhea and vomiting were considered as less common manifestations.
However, asymptomatic cases were also documented and played an important
role on the spread of the infection{[}4{]}.

COVID-19 reinfection was reported before as some patients RT-PCR tested
positive again after recovery. However, the mechanism is not clear and
it is not known yet if affected patients might represent a carriers for
the virus{[}5{]}.

Hemoglobinopathies are well-known widely spread hematological disorders.
Thalassemia is considered one of the most common form of those diseases,
it is mainly due to reduction on either alpha or beta chains, this
defect lead to wide range of clinical presentations. Both thalassemia
Beta or Alpha type might also be categorized into transfusion dependent
or independent.{[}6{]}

Severity of COVID-19 infection has been linked to many factors like the
presence of other comorbidities such as diabetes , immunocompromised
status, elderly and long term diseases like malignancy {[}7{]}. Date
regarding patients with hemoglobinopathies vary in results. However the
majority described a smooth course of infection and a favorable outcome.
{[}8{]}

The current statement from Thalassemia International Federation (TIF)
emphasize on the challenges during providing care for hemoglobinopathies
patients in the epidemic, this concern arises mainly from the lack of
clear evidence regarding COVID-19 infection progression, the need to
visit health care facility frequently for follow up and blood
transfusion{[}2{]}.Thus, TIF also suggests that health care facility
should take extra precaution while dealing with those patients. However,
hemoglobin disorders has not been linked to a respiratory conditions in
a direct way, yet close monitoring is necessary as thalassemia patients
could have multi-organ damage including heart, lungs, liver, endocrine
and immune system due to iron overload which might increase their
COVID-19 complications risk{[}9--13{]}.

Thalassemia patients are usually splenectomized as part of the
therapeutic interventions provided for them, thus they are more
vulnerable for recurrent bacterial infections. Till the day of writing
this case there is no evidence that splenectomy is correlated with an
increased risk of COVID-19 infection and complications{[}14{]}.

Immune response to the pathogens differs among individuals due to
genetic variations. Complications related to the impaired immunity in
Beta Thalassemia patients were considered as an important cause of
morbidity and mortality. Also, iron overload was labeled as the main
reason behind immune deficiency in those patients. However, there is no
evidence regarding iron chelation therapy role in COVID-19 patients with
Beta Thalassemia major . {[}14{]}

To the best of our knowledge there is no reported cases in the
literature for COVID-19 re-infection among hemoglobinopathies patients.
It is worthy to notice that even with re-infection in our case the
episode was smooth and detected with routine screening without even any
respiratory symptoms during the whole quarantine period. However, the
patient has multiple comorbidities, splenectomized, iron overload which
might put her at increased risk for reinfection yet not for
complications.

We suggest that even if Thalassemia patients seem to have a smooth
clinical course of COVID-19 infection, the possibility of being
re-infected should be kept on mind and screening them for COVID-19
infection should be done on each health care contact in order to provide
close monitoring and avoid unexpected deterioration as the long-term out
come is not known, as well due to the risk of spreading the infection
especially if they are asymptomatic like this patient.

COVID-19 reinfection among Thalassemia patients is not reported before,
so more research is needed to consider what pathology might make them
vulnerable or at risk of reinfection. In our case we suggest that the
presence of multiple comorbidities like diabetes, iron overload and
splenectomy are possible reasons. Finally, we would like to raise a
point that even in case of reoccurrence of COVID-19 infection in this
thalassemia beta major patient the outcome still favorable, thus the
recurrence of infection didn't mean poor prognosis or caused any
complications but still important to screen them to control the spread
of COVID-19.

\textbf{Conclusion:}

TIF considered patient with hemoglobinopathies in the vulnerable
categories for COVID-19 complication and emphasized that those patients
need extra precaution during their recurrent visits to the health care
facilities. Mainly due to the lack of current evidence. However,
published literature showed a favorable outcome on the majority of
thalassemia patients who had COVID-19 infection. However, no data was
found regarding the recurrence of this infection. We suggest that all
physician should screen those patients for COVID-19 whenever the visited
the hospital as they might develop asymptomatic recurrence and even
though the clinical course seems to be smooth, screening is essential to
control this pandemic and protect this vulnerable population as their
outcome still unpredictable, thus offering them close monitoring and
controlling their comorbidities.

\textbf{Acknowledgment}

We would like to acknowledge the Hematology section/ oncology
department, Intensive care unit as well as Family medicine residency
program at Hamad Medical Corporation for their support.

Open Access funding provided by the Qatar National Library

\textbf{Statement of Ethics}

Consent was obtained from the patients.

Case approved by HMC Medical Research center

\textbf{Declaration of interest}

The authors report no conflicts of interest.

\textbf{Authors contribution:}

All authors contributed equally to writing the manuscript.

\textbf{Data Availability Statement}

All data related to this article are available upon request.

\textbf{References:}

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Characteristics of 138 Hospitalized Patients with 2019 Novel
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{[}3{]} Song Z, Xu Y, Bao L, Zhang L, Yu P, Qu Y, et al. From SARS to
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{[}6{]} Okar L, Ali M, Parengal J, Yassin MA. COVID-19 and thalassemia
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{[}9{]} Yassin MA, Soliman AT, De Sanctis V, Hussein RM, Al-Okka R,
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\textbf{List of figure and table legends:}

Table 1. comparison between the first presentation and the recurrence.

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