COVID-19 Pneumonia in Bilateral Lung Transplant Recipient: Case Report

Abstract

The clinical course of Coronavirus disease 2019 (covid-19) in lung transplant recipients remains unknown. We present the fatal clinical course of a 63-year-old double lung transplant recipient with severe Covid-19 pneumonia. She had stable graft function before Covid-19 infection. Despite all the supportive care and treatment graft injury progressed, causing patient death. Therefore, the prognosis in lung transplant recipients with Covid-19 infection is not optimistic. CAse RePORt *Corresponding author: Juan Pablo Reig Mezquida, MD, Lung Transplant Unit, Hospital Universitario la Fe, Valencia, Spain, Tel: +0034665116403 Check for updates bilateral lung transplant due to end-stage emphysema. On admission, she was in poor general condition, diarrhea, fever, hypoxemia and tachypnea. Her laboratory results showed impaired renal function with creatinine of 2.45 mg/dL, lymphopenia of 0.06 × 103/μL (5%), C-reactive protein (CRP) of 110.3 mg/L, Procalcitonin of 1.06 ng/mL, D-dimer of 2,571 ng/ml. At that moment, calcineurin inhibitor was replaced by low dose mTOR inhibitor Everolimus. Methylprednisolone was increased to 1 mg/kg and meropenem was started. Prophylactic doses of enoxaparin, hydroxychloroquine (200 mg daily) and Azithromycin 500 mg/24 h were prescribed. During the first 24 h, the patient clinically improved, but on the third day her laboratory test showed a CRP of 203 mg/L, the interleukin-6 (IL-6) levels increased to 308.9 pg/mL, and D-dimer value raised to 60,479 ng/ml. The CT-scan reported extensive ground-glass opacities, affecting the middle lobe, lingula, and lower lobes, with consolidation areas and small left pleural effusion (Figure 1). Everolimus blood levels were 1.8 ng/mL. A single dose of anti-IL-6 antibody Tocilizumab was administered (400 mg IV) and the patient remained respiratory stable and with sustained diuresis. On day 5 of admission, she developed a clinical deterioration, with pO2 of 46 mmHg, and was transferred to the Intensive Care Unit (ICU) where high-flow oxygen therapy was started (FiO2 of 100%, 60 L/min). At this moment, renal function continued worsening, associated with lower T-cell count, and procalcitonin raised to 9.92 ng/mL. ImmunoIntroduction The current pandemic of Coronavirus Disease 2019 (COVID-19) has raised great alarm worldwide, but its impact on transplant patients is unknown, especially in lung transplant recipients. The immunosuppressive maintenance therapy, leads to suppose that the course of this disease could be severe [1]. Spain has a National Transplant Organization which coordinates more than 100 lung transplants per year, and gives support to transplant patients as at-risk population to COVID-19 infection. We report the fatal clinical course of a lung transplant recipient.