Case study 3

Case scenario

32-year old woman 12 months post non-myeloablative HSCT. Previously treated with interferon-beta, mitoxantrone and alemtuzumab. Disabled (EDSS 6.5, swallowing difficulties, recurrent urinary tract infections, bowel problems and frequent falls).

Questions Asked

In MS, is the immune system generally substantially weaker than that of normal people?

No, only if patients are on maintenance or continuous immunosuppressive DMT. As her immune system has reconstituted it should be capable of fighting new infections such as COVID-19.

How 'at risk' is she in her current situation (1 year on from HSCT)? She has been taken off all preventative antibiotics and only does a follow up meeting every 3 - 6 months so we believe her immune system has recovered from HSCT. But what is recovered, would she now have an immune system like a normal person or is it still low by default?

Her immune system has recovered; her immune system will be able to detect and mount an appropriate immune response to a new virus, such as COVID-19. There are studies showing that HSCT rejuvenates the immune system in pwMS; in other words after HSCT it looks younger and more capable of fighting infections. The rejuvenation refers to the so called immune repertoire of the T-cells being broader (many more naive cells) and hence having many more options to choose from to fight infections and prevent her from developing a secondary malignancy.

We have been told that if she starts to show symptoms of infection, that she should just self isolate and only call hospital if it gets worse than, say a cold / flu (just like anyone else) - is this correct or should she get tested straight away? We are worried that if it is left to get worse, then it could be too late.

The most recent government guidance is to only test people who have severe infection and require hospitalisation. If she gets a flu-like illness she needs to stay at home until she recovers. She will not be tested for the virus unless she is admitted to hospital.

If she did catch Covid-19, do you think in her condition that she would likely be able to cope with it or could it be fatal?

I think she would cope with it. This is based on her age and the fact that she doesn't have any other comorbidities. Saying that there are a few young people who do get severe infection and have died from the infection in other countries.

The french authorities are recommending that if people come down with a possible COVID-19 infection they should avoid taking non-steroidal anti inflammatory drugs (NSAIDS), such as ibuprofen, because it can make the infection worse. They recommend using paracetamol or acetaminophen to treat the symptoms. We are not sure why this happens and we are waiting further information on the mechanism underlying this initial observation.

As with any infection pwMS who are disabled can find themselves experiencing worsening of existing symptoms. This is due to temperature-related conduction block, i.e. vulnerable demyelinated axons stop transmitting nervous impulses during a fever. If she does notice worsening it doesn't necessarily mean she is having a relapse.

As she has swallowing problems, which put her at risk of chest infections from micro-aspiration, she is at increased risk of getting a secondary infection is she was infected with COVID-19. For this reason the government has put out guidance that a whole host of patients with neurological disease are at increased risk and for them to socially isolate. Please note this social isolation recommendation is voluntary at present. For this reason she should try and avoid unnecessary social contacts and travel. For information please refer to the Government's website for more information.

Date & Disclaimer: 18-March-2020; please note the information and advice in this case study may change with time.