Lung Transplant for Corona Virus Diseases (COVID-19) Pulmonary Fibrosis

Abstract

Introduction: Persistent radiographic and pulmonary function abnormalities are increasingly recognized following Corona Virus Disease (COVID-19) pneumonia. We present a case of rapidly progressive pulmonary fibrosis in a Usual Interstitial Pneumonia (UIP) pattern. Successful lung transplantation was performed two months following COVID-19 infection. Description: 68 years old with known history of mild Interstitial Lung Disease (ILD) , not on home oxygen, initially presented in July 2020 with worsening shortness of breath and cough. There was a strong family history for Interstitial pulmonary fibrosis (IPF). Her last pulmonary function tests showed a Forced Expiratory Volume in one second (FEV1) of 2.24 Liters (99%) and Forced Vital Capacity of 2.69 Liters (92%). Her last High Resolution Computed Tomography (HRCT) showed chronic stable mild interstitial fibrosis. On admission, she was positive for COVID 19 on her Polymerase Chain Reaction (PCR). Initial CT chest showed diffuse new ground glass changes. She was treated with remdesavir, dexamethasone and antibiotics. She did not require endotracheal intubation and showed improvement in her symptoms. Unfortunately, she could not be weaned off oxygen and was discharged on six liters flow oxygen through a nasal cannula. She presented again to the hospital, one month later with worsening shortness of breath. Her PCR was negative for COVID 19. Her CT angiogram of thorax however showed interval worsening of her interstitial changes. An urgent inpatient evaluation for lung transplantation was completed and she deemed to be a suitable candidate. After 4 days into her stay, acute deterioration in her respiratory status developed with tachypnea and increased work of breathing requiring endotracheal intubation and mechanical ventilation. Repeat CT chest showed fibrotic interstitial disease with associated traction bronchiectasis and a large amount of ground glass. She was subsequently placed on veno-venous Extra Corporeal Membrane Oxygenation (VV ECMO) which allowed extubation. A donor offer for bilateral lungs was accepted after one day on ECMO. She successfully underwent bilateral lung transplant in September 2020. Her post-operative course was uncomplicated. She is doing well 3 months post transplant without evidence of cellular rejection. Her explant pathology showed Diffuse Alveolar Damage plus UIP Discussion: Persistent and progressive pulmonary fibrosis may develop following COVID-19 pneumonia. Risk factors may include underlying ILD and family history of IPF. In suitable candidates, lung transplantation is a viable option.