# Refractory pneumonia due to persistent SARS-CoV-2 infection in an immunocompromised host successfully treated with extended course nirmatrelvir/ritonavir

## TL;DR

A patient with weakened immunity and persistent SARS-CoV-2 infection was successfully treated with a 20-day course of nirmatrelvir/ritonavir after failing other therapies.

## Contribution

Demonstrates successful treatment of persistent SARS-CoV-2 infection in an immunocompromised patient using extended nirmatrelvir/ritonavir therapy.

## Key findings

- The patient's SARS-CoV-2 infection persisted for over 5 months with accumulating genomic mutations.
- Nirmatrelvir/ritonavir treatment led to recovery after other therapies failed.
- The viral strain evolved from XBB to XBB.2.3 over the course of infection.

## Abstract

Immunocompromised individuals are infected with persistent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and often refractory to treatment.

A 56-year-old woman undergoing chemotherapy for follicular lymphoma experienced relapsing pulmonary infiltrates and a consistently low cycle threshold value of nasal swab SARS-CoV-2 PCR over a 5-month period. Despite repeated remdesivir and glucocorticoid therapy, her respiratory symptoms worsened and progressed to respiratory failure. Viral genome analysis revealed that the variant strain at onset was XBB, whereas the strains repeatedly detected more than 2 months after onset were XBB.2.3.

The genome analysis indicated that genomic mutations accumulate due to continuous XBB infection. The patient recovered after treatment with nirmatrelvir/ritonavir for 20 days.