A. Arighi

A.M. Pietroboni

D. Galimberti

E. Scarpini

F. Martinelli Boneschi

G.G. Fumagalli

L. Sacchi

M. Pozzato

M.A. De Riz

T. Carandini

English

AIR Universita degli studi di Milano

https://doi.org/10.1177/1352458520926459
https://doi.org/10.1177/1352458520926459
MULTIPLE
SCLEROSIS MSJ
JOURNAL
journals.sagepub.com/home/msj 1
Multiple Sclerosis Journal
 1 –2
DOI: 10.1177/ 
13524585209264 9
© The Author(s), 2020.  
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permissions
Alemtuzumab in multiple sclerosis 
during the COVID-19 pandemic:  
A mild uncomplicated infection  
despite intense immunosuppression
Date received: 8 April 2020; accepted: 23 April 2020
Italy has been one of the first European countries to 
face the spread of Coronavirus Disease-2019 
(COVID-19). The affected patients have increased 
inexorably worldwide, reaching a pandemic dimen-
sion within a few weeks. The outbreak of COVID-19 
represents a challenge for neurologists treating mul-
tiple sclerosis (MS). No data is available on whether 
patients with MS are at increased risk to develop 
severe forms of COVID-19. Since lymphopenia 
and immunosuppression are associated with worse 
outcomes,1 it is reasonable to hypothesise that 
MS-immunosuppressive treatments may lead to 
more severe infections, but there is no evidence to 
support this.2 We describe a case of mild uncompli-
cated COVID-19 occurring during intense immuno-
suppression a few days after alemtuzumab infusion.
On the same day that the first COVID-19 case was 
reported in Italy (21 February 2020), a 25-year-old 
girl with relapsing-remitting MS – working as a nurse 
in Milan – completed the second cycle of alemtu-
zumab treatment. She had started it 1 year before as 
first-line therapy due to highly active MS, and since 
then she had not experienced clinical relapses or new 
magnetic resonance imaging (MRI) activity. One 
week after the first Italian COVID-19 case, the patient 
was advised to stay home from work, due to the 
alarming spread of new affections. Nevertheless, 
7 days later, she complained of dry cough, fatigue and 
fever up to 38.5°C. She was isolated at home and self-
monitored blood oxygen saturation – which was 
always within normal range – and took acetami-
nophen. Symptoms gradually disappeared over 
3 days, apart from cough that persisted for approxi-
mately 10 days. One week after symptom onset, she 
underwent nasopharyngeal swab for SARS-CoV2. 
On the same day, a blood test revealed a 
severe leukopenia with neutropenia and lymphopenia 
(leukocytes 1.19 × 109/L, granulocytes-neutrophils 
0.75 × 109/L, lymphocytes 0.09 × 109/L), but no ele-
vation of inflammatory markers. Two weeks after the 
first swab, the second one was negative and the patient 
was asymptomatic (Supplementary material).
Alemtuzumab causes the depletion of CD52-expressing 
cells, leading to a transient alteration in lymphocyte 
numbers, trafficking and function after each course, 
and thus to an increased risk of infection,2,3 including 
both upper (very common; ⩾10%) and lower respira-
tory tract infections (common; 1%–10%).4 The risk of 
COVID-19 in alemtuzumab-treated MS patients is 
unknown, but a higher risk is conceivable. For these 
reasons, Brownlee et al.2 recently recommended that 
alemtuzumab should not be initiated in MS patients 
who are about to start a treatment, and, for those already 
on treatment, to delay further courses, considering the 
risks and benefits. We described the case of a young 
woman who had COVID-19 few days after alemtu-
zumab infusion. Her blood counts were in line with the 
study by Li et al.,5 reflecting an intense immunosup-
pression. Nonetheless, the patient had a mild infection 
and recovered within 2 weeks. On one hand, it should 
be noted that being a young woman without other med-
ical conditions probably decreases the risk that COVID-
19 results in severe illness. On the other hand, our 
report highlights the possibility that mild courses of 
COVID-19 may exist despite immunosuppression and 
that the spectrum of illness severity does not necessar-
ily follow patient’s immune status. Further reports are 
needed to clarify the link between COVID-19 risk/
severity/disease status and concomitant immunosup-
pressive medications.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts 
of interest with respect to the research, authorship and/
or publication of this article: A.M.P., M.A.D.R. and 
F.M.B. have received conference fees and compensa-
tion for travel grants from Genzyme, Merck-Serono, 
Biogen and Roche. T.C., L.S., M.P., A.A., G.G.F., D.G. 
and E.S. declare no potential conflicts of interest.
Funding
The author(s) received no financial support for the 
research, authorship and/or publication of this 
article.
ORCID iDs
Tiziana Carandini  https://orcid.org/0000-0002 
-0568-7580
Anna Margherita Pietroboni  https://orcid.org/0000 
-0003-1538-1830
Filippo Martinelli Boneschi  https://orcid.org/0000 
-0002-9955-1368
926459MSJ0010.1177/1352458520926459Multiple Sclerosis JournalT Carandini, AM Pietroboni et al.
letter20202020
Letter
Multiple Sclerosis Journal 00(0)
2 journals.sagepub.com/home/msj
Supplemental material
Supplemental material for this article is available 
online.
References
1.  Zhou F, Yu T, Du R, et al. Clinical course and risk 
factors for mortality of adult inpatients with 
COVID-19 in Wuhan, China: A retrospective cohort 
study. Lancet 2020; 395(10229): 1054–1062.
2.  Brownlee W, Bourdette D, Broadley S, et al. 
Treating multiple sclerosis and neuromyelitis optica 
spectrum disorder during the COVID-19 pandemic. 
Neurology. Epub ahead of print 2020. DOI: 10.1212/
WNL.0000000000009507.
3.  Coles AJ, Twyman CL, Arnold DL, et al. 
Alemtuzumab for patients with relapsing multiple 
sclerosis after disease-modifying therapy: A 
randomised controlled phase 3 trial. Lancet 2012; 
380(9856): 1829–1839.
4.  Bianco A, Mari P-V, Larici AR, et al. Alemtuzumab-
induced lung injury in multiple sclerosis: Learning 
from adversity in three patients. Mult Scler Relat 
Disord 2020; 37: 101450.
 5. Li Z, Richards S, Surks HK, et al. Clinical 
pharmacology of alemtuzumab, an anti-CD52 
immunomodulator, in multiple sclerosis. Clin Exp 
Immunol 2018; 194(3): 295–314.
Tiziana Carandini1 , Anna Margherita 
Pietroboni1 , Luca Sacchi1,2, Milena Alessandra 
De Riz1, Mattia Pozzato1,2, Andrea Arighi1, Giorgio 
Giulio Fumagalli1, Filippo Martinelli 
Boneschi1,2 , Daniela Galimberti1,2  
and Elio Scarpini1,2
1Fondazione IRCCS Ca’ Granda, Ospedale 
Maggiore Policlinico, Milan, Italy 
2University of Milan, Milan, Italy
Correspondence to: 
T Carandini 
Fondazione IRCCS Ca’ Granda, Ospedale  
Maggiore Policlinico, Via Francesco Sforza 35, 
Milan 20122, Italy. 
tizianacarandini@gmail.com
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Alemtuzumab in multiple sclerosis during the COVID-19 pandemic: A mild uncomplicated infection despite intense immunosuppression

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Alemtuzumab in multiple sclerosis during the COVID-19 pandemic: A mild uncomplicated infection despite intense immunosuppression

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