Sex: F
Vaccine: COVID19, COVID19
Symptoms: Body mass index, Breakthrough COVID-19, Drug ineffective, Investigation, Nucleic acid test
Clinical narrative: boosted and SARS-CoV-2 naïve. She subsequently tested positive on nasal RT-PCR as well as RT-LAMP within hours and developed a sore throat; boosted and SARS-CoV-2 naïve. She subsequently tested positive on nasal RT-PCR as well as RT-LAMP within hours and developed a sore throat; This is a literature report for the following literature source(s):   A 37-year-old female with Hashimoto's thyroiditis and insulin resistance on 100 mcg of L-thyroxin and 1000 mg of metformin daily, tested positive for SARS-CoV-2 on a BD Veritor lateral flow test (LFT) as she had been exposed to SARS-CoV-2 36 h prior at an outdoor event. She was vaccinated, boosted and SARS-CoV-2 naive. She subsequently tested positive on nasal RT-PCR as well as RT-LAMP within hours and developed a sore throat. Owing to a BMI of 43 was Paxlovid started. Next morning, the sore throat continued and the patient was also started on Lagevrio due to a family history and concerns of Long Covid. Sore throat subsided on Day 3, with positive on RT-PCR, RT-LAMP, and LET until Day 4. The patient continued Lagevrio for 5 days and Paxlovid for 10 days tolerating them well except for dysgeusia. The patient was also enrolled in a COVID-19 immunity study performing serum epitope repertoire analysis (SERA) of antibodies against SARSCOV-2.9. SERA, 3 weeks post infection demonstrated decreased antibody levels, and a minor change in motifs, indicating that the antivirals stopped the viral replication and blunted the immune response. The change in motifs as well as the patient's pre- and post-infection antibody profile are consistent with vaccine-induced antibodies against the spike glycoprotein and no antibodies against the nucleocapsid. While some patients do not mount antibodies against the nucleocapsid post infection, lO the combination of decreasing titers, as well as no "evolutlon" of the motifs against the onginal spike, in the background of BA4/5 dominance, effectively indicate that from an immunological perspective the infection was as if it never happened. Furthermore, stopping viral replication and release, antivirals may have led to favoring of apoptosis, with increased innate immune response to cell debris versus adaptive response. Furthermore, CDC recommends waiting at least 2 months post-COVlD-19 for a booster. However, in light of antivirals possibly suppressing immune responses against COVID19 a more prudent approach may be to boost patients to ensure appropriate immune response while on Paxlovid. That is, instead of Test and Treat, Pax and Boost; especially that the public and clinicians stick to the old codicil that a COVID-19 infection leads to long-lasting immunity. Future studies should look if antivirals have any effect on Long Covid, if combination of Paxlovid and Lagevrio leads to better outcomes, if delayed initiation of antivirals leads to better immunological outcomes, if a 10-day course of Paxlovid minimizes risk of rebound, and if a Pax and Boost strategy would be beneficial. This case is also limited by lack of laboratory measurements as well as further immune response analysis outside of the antibody responses, however, in the absence of symptoms, the value of such data would have been limited. Although this case is anecdotal, in light of rapidly evolvlng data as well as sheer scale of a "secondary" pandemic of Long Covid, raises important questions that need to be answered by investigators studying the SARS-CoV-2 and its sequelae.; Sender's Comments: Based on the information provided, a causal relationship between the suspected drug and the reported events drug ineffective, SARS-CoV-2 infection post vaccine cannot be excluded