New onset of autoimmune diseases in patients with primary antibody deficiency and CD4 lymphopenia after COVID-19

Patients with primary antibody deficiency (PAD) have increased susceptibility to infectious and non-infectious complications including autoimmune diseases. It is speculated that SARS-CoV-2 can disturb self-tolerance and trigger autoimmune responses in COVID-19. Here, we present two cases of patients with PAD who developed new onset of autoimmune disease after COVID-19. We performed chart review of two cases using electronic medical records. Case 1: A 58 year old female with common variable immune deficiency (CVID) was hospitalized for COVID-19 pneumonia which required high dose steroid. As the steroid was tapered, she developed significant dyspnea. EKG revealed new onset of left bundle branch block and echocardiogram showed ejection fraction of 48%. Cardiac MRI was consistent with myocarditis with abnormal T2 mapping. Upon immune work up, CD4 count was 239 cells/mm3. Case 2: A 66 year old female with a history of selective IgG subclass 2 deficiency and CD4 lymphopenia (111 cells/mm3) developed increasing dyspnea over the two months after SARS-CoV-2 infection. This did not improve with multiple courses of antibiotics. CT chest showed multiple enlarged mediastinal lymph nodes, biopsy of which revealed non-necrotizing granulomatous inflammation, consistent with sarcoidosis. We believe these are the first reported cases for new onset of autoimmune diseases after COVID-19 in PAD patients. New onset autoimmune disease should be considered in patients with PAD especially with CD4 lymphopenia who experience prolonged dyspnea after COVID-19.