Impact of SARS-CoV-2 in Hematopoietic Stem Cell Transplantation and Chimeric Antigen Receptor T Cell Therapy Recipients

Muhammad Umair Mushtaq, Moazzam Shahzad, Sibgha Gull Chaudhary, Mary Luder, Nausheen Ahmed, Haitham Abdelhakim, Rajat Bansal, Ramesh Balusu, Shaun DeJarnette, Clint Divine, Robert Kribs, Leyla Shune, Anurag K. Singh, Siddhartha Ganguly, Sunil H. Abhyankar, Joseph P. McGuirk

Research output: Contribution to journalArticlepeer-review

34 Scopus citations


Coronavirus disease 2019 (COVID-19), a respiratory illness caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic in March 2020, and has caused more than 600,000 deaths in the United States at the time of this report. Hematopoietic stem cell transplantation (HCT) or chimeric antigen receptor T cell (CAR-T) therapy recipients have a higher risk of mortality with COVID-19 owing to profound immune dysregulation. In this study, we investigated the impact of SARS-CoV-2 in HCT/CAR-T therapy recipients. This single-center prospective study included all (n = 58) adult HCT/CAR-T recipients who were diagnosed with COVID-19 at the University of Kansas Medical Center between March 2020 and May 2021. Baseline and disease-related characteristics were ascertained from medical records. Data were analyzed using SPSS version 21 (IBM, Armonk, NY). Bivariate analyses, using the chi-square and t-test, and logistic regression analyses were conducted. The study included 58 HCT/CAR-T patients who acquired SARS-CoV-2 infection, including recipients of allogeneic HCT (n = 32), autologous HCT (n = 23), and CAR-T therapy (n = 3). The median patient age was 58 years (range, 24 to 77 years), and 64% were males. The median time from HCT/CAR-T therapy to SARS-CoV-2 infection was 17.7 months (range, 0.2 to 201.9 months), and 22% of the patients acquired SARS-CoV-2 within the first 100 days post-HCT/CAR-T therapy. The primary hematologic disorders were plasma cell (36%), myeloid (38%), and lymphoid (26%) malignancies. Myeloablative conditioning was performed in 62% of patients. Donors were autologous (45%), matched sibling (15%), matched unrelated (21%), and haploidentical (19%). Prior history of grade II-IV acute graft-versus-host disease (GVHD), active GVHD, and current immunosuppressive therapy (IST) was noted in 22%, 31%, and 36% of patients, respectively. Concurrent infections were observed in 19%. Lymphopenia (P =.049) and high serum ferritin concentration (P =.020) were associated with mortality. COVID-19 severity was mild in 50% of the patients, moderate in 22%, and severe in 28%. Clinical findings included pneumonia or abnormal chest imaging (in 50%), hypoxia (28%), intensive care unit admission (19%), and mechanical ventilation (10%). Therapies included remdesivir (in 41%), convalescent plasma (35%), dexamethasone (22%), monoclonal antibodies (19%), and tocilizumab (3%). The median duration of viral shedding (positive SARS-CoV-2 PCR) was 7.7 weeks (range, 2 to 18.7 weeks), and 2 patients had a persistent infection for >5 months post-CAR-T therapy. After a median follow-up of 6.1 months (range, 0.5-13.6 months), the mortality rate was 16% in all patients and 28% in allogeneic HCT recipients. Among 9 patients who died, the median survival after SARS-CoV-2 infection was 23 days (range, 14 to 140 days). In survivors with moderate-severe COVID-19, the median time to recovery was 4.2 weeks (range, 1.1 to 24.7 weeks). Among allogeneic HCT recipients, 5 (16%) developed subsequent pulmonary chronic GVHD necessitating systemic steroids and additional IST. Significant predictors of COVID-19 severity included allogeneic HCT (odds ratio [OR], 3.6, 95% confidence interval [CI], 1.2 to 10.8; P =.020), history of grade II-IV acute GVHD (OR, 4.6; 95% CI, 1.10 to 18.86; P =.036) and concurrent IST (OR, 5.9; 95% CI, 1.8 to 19.8; P =.004). HCT and CAR-T cell therapy recipients are at an increased risk of moderate-severe COVID-19 pneumonia and higher mortality with SARS-CoV-2 infection. Our findings confirm the need for continuing vigilance with social distancing and masks, vaccination prioritization, close monitoring, and aggressive treatment of HCT/CAR-T therapy recipients.

Original languageEnglish (US)
Pages (from-to)796.e1-796.e7
JournalTransplantation and Cellular Therapy
Issue number9
StatePublished - Sep 2021


  • Cellular therapy
  • Chimeric antigen receptor T cell therapy
  • Coronavirus disease 2019
  • Hematologic malignancies
  • Hematopoietic stem cell transplantation
  • Severe acute respiratory syndrome coronavirus 2
  • Hematopoietic Stem Cell Transplantation/adverse effects
  • Prospective Studies
  • United States
  • Humans
  • Middle Aged
  • Receptors, Chimeric Antigen
  • Male
  • Young Adult
  • SARS-CoV-2
  • Immunization, Passive
  • Adult
  • Aged
  • COVID-19/therapy

ASJC Scopus subject areas

  • Transplantation
  • Medicine(all)
  • Molecular Medicine
  • Hematology
  • Immunology and Allergy
  • Cell Biology


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