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1)
Patients with a known exposure, as well as acutely ill patients with primary immunodeficiency with or without a history of a known exposure, must be investigated for SARS-Cov-2. It is particularly important for patients known to have T-cell immunodeficiency, athymia, or SCID to seek medical care immediately on presentation of symptoms (fever, cough).
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2)
Monitoring for infections other than SARS-CoV-2 is required. Immunodeficiency patients may have a myriad of infections other than SARS-CoV-2 (such as liver abscesses, osteomyelitis, meningitis, bacteremia, and PJP, and all of these would require face-to-face evaluation if suspected). Patients with bronchiectasis in particular may need close monitoring, given infectious issues at baseline related to this that may place such individuals at risk. Patients with central lines and/or neutropenia will still require blood cultures and antibiotics if they become ill (depending on their clinical scenario).
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3)
New cases of suspected SCID or other T-cell deficiencies should continue to be seen and assessed as would occur under normal service operations. Such patients should be brought back to a clean room immediately on arrival to the clinic/office. It may be reasonable to initially evaluate consultations for abnormalities on newborn screening by telehealth.
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4)
Radiographic service access may be needed to help distinguish between COVID-19 and what could be a lobar or otherwise complicated pneumonia (bacterial).
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5)
If a patient has not already transitioned immunoglobulin replacement therapy to home services (IV/SC), they will still need to come into their infusion centers. Plans must be made to ensure that home immunoglobulin replacement services continue, because this is an urgent therapy. It is unlikely that any current immunoglobulin supply has SARS-CoV-2 antibody protection or is contaminated with the virus. Given that this is a donor-dependent therapy, this could affect future supplies. Patient may wish to consider transitioning to home immunoglobulin replacement (IV/SC).
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6)
Autoimmune phenomena must be tended to promptly. Concern for autoimmune cytopenias or enteropathy need prompt evaluation, treatment, and monitoring.
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7)
For those patients receiving various immunosuppressive agents that require therapeutic drug-level monitoring, phlebotomy services must be accessible to monitor for toxicities. This is critical for autoimmune and transplant (BMT/solid-organ) patients.
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8)
Patients who are also being treated for malignancy should continue receiving chemotherapy.
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9)
Telehealth should be considered for routine/annual follow-up, and in many cases it may be reasonable to defer routine monitoring labs, imaging, and PFTs for several months.
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10)
Telehealth may be considered for acute visits for possible infections that are low acuity (ie, otitis media, sinusitis, and superficial skin infections).
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11)
Telehealth may be considered for initial consultations of patients referred for possible immunodeficiency; however, in some circumstances, face-to-face evaluations and access to ancillary laboratory services may be needed.
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12)
Clinicians should review routine self-care examination measures with patients, such as palpation of lymph nodes, joints, and cavities that in some conditions may be prone to abscess development, and recommend to patients a frequency with which these should be performed.
