TYPE: Medical Student/Resident Case Reports
INTRODUCTION: Immunosuppressed lung transplant recipients (LTxRs) are predisposed to severe SARS-CoV-2 disease, impaired virus clearance, and increased mortality. Successful recovery from SARS-CoV-2 infection after reduction of immunosuppression (IS) has been reported in kidney and heart transplant recipients [1,2]. We report a case of favorable allograft outcome after reduction of IS in an LTxR with SARS-CoV-2 pneumonia despite prolonged virus shedding.
CASE PRESENTATION: A 58-year-old bilateral LTx recipient (July 2020) with blood type A+ was admitted for a positive SARS-CoV-2 RT-PCR result from a nasal wash on July 31, 2020 (day 1). He exhibited fever, increasing shortness of breath, a productive cough, and bilateral radiographic infiltrates, but normal oxygen saturation on room air and stable pulmonary function tests (FVC and FEV1 at 3.17 and 2.65 liters, respectively). Shortly after hospitalization, his dyspnea and oxygen requirement increased (3 LPM) and inflammatory markers were elevated (nadirs of lymphocyte 2.7 thousand/µL and platelet 158 thousand/µL; peaks of D-dimer 260 ng/mL, CRP 75.2 mg/L, ferritin 219 ng/mL, pro-calcitonin 0.22 ng/mL, and LDH 215 U/L). Imaging favored progression of SARS-CoV-2 pneumonia. DSA against DP1 measured 1350 MFI, and immunoglobulin therapy was started. The patient was managed with intravenous corticosteroid pulse, Remdesivir, and convalescent plasma along with appropriate antibiotic therapy due to additional concern for superimposed infection. On day 8 of illness onset, the patient no longer had clinical symptoms, and he was discharged on room air and steroid taper. On outpatient follow-up, the patients' endurance had increased; PFTs improved (FVC and FEV1 at 3.9 and 3.39 L, respectively); DSAs were reassuring; and radiographic changes had resolved by day 42 (Figure 1: serial chest imaging from illness onset to day 42). Of note, the ImmuKnow result at illness onset was 64 ng/mL, and mycophenolate (MMF) was reduced to 500 mg BID, after which the ImmuKnow result increased to 560 ng/mL. Seroconversion for SARS-CoV-2 IgG was mounted on day 26 (index 1.56), and MMF was resumed to baseline dose of 750 mg BID on day 35. Remarkably, prolonged viral shedding in nasal wash was noted with the first negative RT-PCR for SARS-CoV-2 on day 47.
DISCUSSION: Our patient had excellent recovery with intact graft function despite prolonged virus persistence. Although an immunosuppressed state may have predisposed our patient to bacterial superinfection, reduction of MMF possibly augmented the antiviral response. Despite reduced IS, seroconversion and virus clearance may have been impacted.
CONCLUSIONS: Immunosuppressed LTxRs with SARS-CoV-2 pneumonia may demonstrate prolonged viral shedding. Reduction in IS may facilitate allograft recovery despite delayed PCR conversion. Isolation measures should be considered due to possible prolonged infectivity.
REFERENCE #1: Li F, Cai J, Dong N. First cases of COVID-19 in heart transplantation from China. J Heart Lung Transplant. 2020 May;39(5):496-497.
REFERENCE #2: Zhu L, Xu X, Ma K, Yang J, Guan H, Chen S, Chen Z, Chen G. Successful recovery of COVID-19 pneumonia in a renal transplant recipient with long-term immunosuppression. Am J Transplant. 2020 Jul;20(7):1859-1863.
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