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.