To the Editor: Patients with malignancies are at risk of poor outcomes from COVID-19.1 In particular, the death rate of patients with hematologic malignancies is reported to be 14% within 1 month of COVID-19 diagnosis.2 It remains unclear whether patients with cutaneous lymphomas are at comparable risk. One study reported that patients with cutaneous lymphomas infected with SARS-CoV-2 have the same susceptibility and outcomes as those without cutaneous lymphomas infected with SARS-CoV-2.3 However, advanced age and long-term immunosuppressive therapy may place patients with cutaneous lymphomas at risk of life-threatening complications.4, 5 We aimed to assess the impact of COVID-19 on patients with primary cutaneous T-cell lymphomas (CTCLs) at our institution.
Our study was conducted with the approval of the institutional review board at the University of Michigan. We retrospectively reviewed patient records for individuals diagnosed with CTCL at Michigan Medicine from 2010 to 2022. Patients deceased before February 1, 2020, were excluded. In our cohort of 384 patients with cutaneous lymphoma seen in our health system since January 1, 2010, we identified 24 patients with CTCL who tested positive for COVID-19. To understand the risk factors for patients who tested positive for COVID-19, we performed a retrospective analysis of lymphoma-related disease history.
A summary of the patient demographics and CTCL history at the time of COVID-19 infection is provided in Table I. Our cohort includes 13 men and 12 women with a median age of 57.08 years (range, 18-88 years). Diagnoses ranged from lymphomatoid papulosis to mycosis fungoides with large cell transformation, leukemic involvement, or erythroderma (Sezary syndrome). The majority of cases were patients with stage IA or IB disease (13 cases, 52%). A smaller subset had stage II-IV disease (Table II). Seven cases (28%) were being treated with systemic approaches.
Table I.
Clinical summary of CTCL patients with COVID-19
| Demographics | Number of cases (%) |
|---|---|
| Sex | |
| Male | 13 (52.0) |
| Female | 12 (48.0) |
| Age, y, median (range) | 57.08 (18-88) |
| Race/ethnicity | |
| White | 20 (80.0) |
| Black | 3 (12.0) |
| Hispanic | 1 (4.0) |
| Not specified | 1 (4.0) |
| Diagnosis | |
| MF, NOS | 7 (28.0) |
| Folliculotropic MF | 3 (12.0) |
| MF-LCT | 2 (8.0) |
| MF with leukemic involvement | 1 (4.0) |
| Sezary syndrome | 2 (8.0) |
| CD4+ lymphoproliferative disorder | 2 (8.0) |
| Hypopigmented MF | 2 (8.0) |
| MF with LyP | 2 (8.0) |
| CTCL-NOS | 1 (4.0) |
| Syringotropic MF | 1 (4.0) |
| LyP | 2 (8.0) |
| Duration of disease, mo, mean (range) | 55 (1-156) |
| Stage at COVID-19 diagnosis | |
| IA/B | 13 (52.0) |
| IIA/B | 3 (12.0) |
| III-IV | 3 (12.0) |
| LyP | 2 (8.0) |
| Quiescent | 3 (12.0) |
| Unavailable | 1 (4.0) |
LCT, Large cell transformation; LyP, lymphomatoid papulosis; MF, mycosis fungoides; NOS, not otherwise specified.
Table II.
Demographics, CTCL disease history, and COVID-19 related outcomes
| Case | Age | Sex | Ethnicity | Diagnosis | Stage | Lymphoma treatment | Duration of disease (mo) | Comorbidities | COVID-19 vaccination history | Hospitalization for COVID-19 | Complication from COVID-19 | Status after COVID-19 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 76 | M | White | MF, NOS | IA | Triamcinolone | 43 | Hypertension, obesity | 3 doses | No | N/A | Living |
| 2 | 35 | M | White | MF, NOS | IA | Triamcinolone | 36 | Asthma, smoking history | 0 doses | No | N/A | Living |
| 3 | 58 | F | White | MF, NOS | IA | Clobetasol | 121 | Hypertension, obesity, smoking history | 3 doses | No | N/A | Living |
| 4 | 67 | F | White | MF, NOS | IA | Betamethasone, UV-B phototherapy | Unknown (>20 years) | None | 2 doses | Yes | Pneumonia, ARDS | Living |
| 5 | 58 | F | Black | CTCL, NOS | 1A | Betamethasone, psoralen–UV-A with methoxsalen | 35 | Hypertension, obesity, smoking history | 0 doses∗ | No | N/A | Living |
| 6 | 50 | F | White | MF-LyP | IA | Triamcinolone | 26 | None | 0 doses | No | N/A | Living |
| 7 | 18 | M | White | MF -LyP | IA | UV-B phototherapy, desoximetasone | 26 | None | 0 doses∗ | No | N/A | Living |
| 8 | 63 | F | Black | Hypopigmented MF | IA | Triamcinolone | 74 | Hypertension, smoking history | 0 doses∗ | No | N/A | Living |
| 9 | 74 | F | White | MF, NOS | IB | Triamcinolone | 46 | Asthma, smoking history | 0 doses∗ | No | N/A | Living |
| 10 | 44 | M | Hispanic | MF, NOS | IB | Triamcinolone, hydrocortisone, fluocinolone, Vitamin D, prednisone, methotrexate | 48 | Hypertension, obesity, smoking history | 1 dose | Yes | N/A | Living |
| 11 | 25 | M | N/A | Hypopigmented MF | IB | Natural sunlight therapy, Triamcinolone | 48 | None | 0 doses | No | N/A | Living |
| 12 | 65 | F | White | Folliculotropic MF | IB | Targretin, Triamcinolone | 72 | Hypertension | 0 doses∗ | No | N/A | Living |
| 13 | 73 | M | White | Folliculotropic MF | IB | Clobetasol, triamcinolone, UV-B phototherapy, mupirocin | 40 | Smoking history | 1 dose | No | N/A | Living |
| 14 | 78 | F | White | MF with leukemic involvement | IB | Mogamulizumab, betamethasone, triamcinolone | 89 | Hypertension | 0 doses∗ | No | N/A | Living |
| 15 | 49 | M | Black | Folliculotropic MF | IIB | Targretin, urea, fluocinonide, triamcinolone | 23 | Smoking history | 3 doses | No | N/A | Living |
| 16 | 27 | F | White | MF-LCT | IIB | Pralatrexate, clobetasol, triamcinolone, UV-B phototherapy | 6 | None | 0 doses | No | N/A | Living |
| 17 | 57 | F | White | MF-LCT | IIB | Mogamulizumab, doxycycline, clobetasol, radiation | 72 | Obesity, smoking history | 2 doses | No | N/A | Living |
| 18 | 73 | M | White | Sezary syndrome | IV | Mogamulizumab, clobetasol, triamcinolone | 11 | Hypertension | 2 doses | Yes | Readmission for delirium | Living |
| 19 | 88 | M | White | MF, NOS | IVA1 | Doxycycline, clobetasol, hydroxyzine, ibrutinib | 53 | Waldenstrom’s macroglobulinemia | 0 doses∗ | Yes | Pneumonia | Deceased |
| 20 | 74 | M | White | Sezary syndrome | IV | ECP, triamcinolone | 1 | COPD, smoking history | 3 doses | No | ECP treatment delay | Living |
| 21 | 74 | F | White | Syringotropic MF | Quiescent | Observation | 141 | Smoking history | 0 doses | No | None | Living |
| 22 | 27 | M | White | LyP | N/A | Clobetasol | 28 | None | 2 doses | No | None | Living |
| 23 | 66 | F | White | LyP | N/A | Observation | 156 | Smoking history | 0 doses∗ | No | None | Living |
| 24 | 53 | M | White | CD4 Lymphoproliferative disease | Quiescent | Observation | 52 | Diabetes mellitus, kidney transplant, hypertension, obesity | 2 doses | No | None | Living |
| 25 | 55 | M | White | CD4 Lymphoproliferative disease | Quiescent | Observation | 73 | Obesity | 0 doses | No | None | Living |
ARDS, Acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; ECP, extracorporeal photopheresis; F, female; LCT, large cell transformation; LyP, lymphomatoid papulosis; M, male; MF, mycosis fungoides; NOS, not otherwise specified.
Infection before vaccine availability.
Individual cases are described in Table II. Of note, 4 patients were hospitalized because of COVID-19, including 2 of the 3 patients with advanced disease (stage III-IV). One of these patients died because of complications from COVID-19 (case 19). The other patient with advanced disease (case 20) experienced an extracorporeal photopheresis treatment delay because of symptoms and visitation policies, suggesting that COVID-19 infection may have indirect effects on CTCL outcomes.
Our retrospective analysis suggests that patients with CTCL, particularly those with advanced disease, are at risk of severe COVID-19. Our study has several limitations, including its small sample size and retrospective design. Given a multitude of factors, including barriers to testing and asymptomatic infections, it is likely that our findings are skewed toward severe disease. Nonetheless, our findings emphasize the importance of risk-reduction counseling for at-risk patient populations, including those with CTCLs.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: Drs Tsoi and Tejasvi are supported by UMHS-PUHSC Joint Institute Discovery Award.
IRB approval status: Reviewed and approved by the institutional review board at the University of Michigan (approval no. HUM00155110).
References
- 1.Zhang H., Han H., He T., et al. Clinical characteristics and outcomes of COVID-19-infected cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst. 2021;113(4):371–380. doi: 10.1093/jnci/djaa168. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kuderer N.M., Choueiri T.K., Shah D.P., et al. Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study. Lancet. 2020;395(10241):1907–1918. doi: 10.1016/S0140-6736(20)31187-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Elmasry M.F., Youssef R., Elbendary A., Helmy K., Abdelkader H.A. Cutaneous lymphomas and COVID-19: what is known so far? Dermatol Ther. 2021;34(1) doi: 10.1111/dth.14463. [DOI] [PubMed] [Google Scholar]
- 4.Zic J.A., Ai W., Akilov O.E., et al. United States cutaneous lymphoma consortium recommendations for treatment of cutaneous lymphomas during the COVID-19 pandemic. J Am Acad Dermatol. 2020;83(2):703–704. doi: 10.1016/j.jaad.2020.04.049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sánchez-Velázquez A., Bauer-Alonso A., Estrach T., et al. Patients with primary cutaneous lymphoma are at risk for severe COVID-19. Data from the Spanish primary cutaneous lymphoma registry. J Eur Acad Dermatol Venereol. 2021;35(10):e624–e626. doi: 10.1111/jdv.17430. [DOI] [PMC free article] [PubMed] [Google Scholar]