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.