Laya Ohadi1 MD, Fatemeh
Hosseinzadeh2 MD, Sahar Dadkhahfar*2MD Soheila Nasiri*2 MD
*Correspondence:
Sahar.dadkhahfar@gmail.com
Nasiri_s@hotmail.com2Skin Research Center, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
Full list of author information is available at the end of the article
Introduction
Cutaneous T-cell lymphomas (CTCL) that are characterized by accumulation
of malignant T lymphocytes in the skin, are rare types of non-Hodgkin
lymphoma (1, 2).The most common variant is mycosis fungoides (MF) with
characteristic patches, plaques, and tumors arising in the skin and an
indolent behavior(2-4). Patients with MF often experience a chronic
course of disease, with waxing and waning skin lesions(4). The
spontaneous regression (SR) although rare, may occur; however, the
factors that predict SR have not been identified yet(5).
Previously, complete remission (CR) of cutaneous T-cell lymphoma was
reported in an HIV-infected patient associated with a falling CD4
count(6).
Since the beginning of the COVID-19 pandemic studies have shown a clear
decrease in peripheral lymphocytes and natural killer (NK) cells in
COVID-19 patients(7). In fact, the lympho-depletion induced by severe
acute respiratory syndrome coronavirus 2 (Sars-Cov-2) has a crucial
diagnostic role and represents a valid prognostic tool(8). Here we
report an interesting case of refractory MF after COVID-19.
Case Presentation
In August 2020, a 64-years-old male presented with severe symptoms such
as dry cough and dyspnea related to COVID-19 infection, confirmed by
both chest tomography (CT) scan and oropharyngeal swab polymerase chain
reaction (PCR). He was treated in outpatient setting by receiving
supportive medications and maintaining home quarantine. No other
specific drugs were administered.
His past medical history was positive for MF, diabetes, hyperlipidemia
and ischemic heart disease. His drug history was Metformin 1000
milligrams (mg) three times a day, Rosuvastatin 10 mg daily, Aspirin 80
mg daily and Nitroglycerin 2.6 mg daily. Lab test was only significant
for a mild lymphopenia.
The patient had been diagnosed with early patch MF after a five-month
history of pruritus and erythematous patches scattered over trunk and
upper and lower extremities, back in November 2018. His condition was
confirmed by skin biopsy and immuno-histochemical studies.
The patient showed partial remission with several courses of ultraviolet
B (UVB) (79 sessions between December 2018 and May 2020).
Three weeks after improvement of COVID-19, our patient experienced
complete remission of all of MF related lesions. For six months, he was
symptom free but after six months, some of his lesions recurred but with
lesser severity and limited distribution on back.
Discussion
The surprising clinical improvement of our case may suggest an
antineoplastic role for SARS-CoV-2 infection, as if the virus had acted
as an oncolytic agent. This case experienced the remission of his
condition 21 days after complete clearance of COVID-19 infection
confirmed by negative oropharyngeal swab PCR; however, recurrence of
itching and skin patches was noticed after few months.
Several studies have illustrated an oncolytic role for a variety of
viruses. The antitumor immunomodulatory actions triggering
lympho-depletion are well established. In fact, oncolytic viruses are
engineered to express some cytokines, including tumor necrosis factor
alpha (TNF-a) and interleukin-2 (IL-2) to deplete T cells, as a part of
adoptive therapy(9, 10).
Furthermore, oncolytic viruses can exert antitumor activity that cause
lymphocytic cells reduction identical to high dose chemotherapy(11). The
underlying mechanism for improvement of MF after COVID-19 maybe related
to the large amount of pro-inflammatory cytokines, such as interleukin 6
(IL-6), TNF-a, IL-2 release during COVID-19 infection that attract T and
NK cells to the neoplastic T-cells(11, 12).
On the other hand, the SARS-CoV-2 could be a probable pivotal element in
the apparent improvement of clinical features related to MF similar to
human immunodeficiency virus (HIV)(6, 12). Furthermore, in a previous
report an HIV seropositive patient developed MF that was surprisingly
improved after development of apparent HIV disease(6).
Conclusion
This case report supports the antineoplastic effect of SARS-CoV-2 which
has been previously suggested in a case of African 20-years-old male
with a temporary remission of refractory NK/T-cell lymphomas after
COVID-19 infection but relapse after recovery from SARS-CoV-2(12). The
underlying mechanism of T cell depletion or oncolytic effects of
COVID-19 in not known and further studies are needed to elucidate this
possible role.