key: cord-286915-lhxg4vjn
authors: Keller, Brian C.; Le, Anh; Sobhanie, Mahdee; Colburn, Nora; Burcham, Pamela; Rosenheck, Justin; Howsare, Molly; Ganapathi, Asvin M.; Atyia, Sara A.; Haden, Michael; Whitson, Bryan A.; Mokadam, Nahush A.; Nunley, David R.
title: Early COVID‐19 infection after lung transplantation
date: 2020-06-11
journal: Am J Transplant
DOI: 10.1111/ajt.16097
sha: 
doc_id: 286915
cord_uid: lhxg4vjn

COVID‐19, the clinical syndrome caused by the novel coronavirus, SARS‐CoV‐2, continues to rapidly spread, leading to significant stressors on global healthcare infrastructure. The manifestations of COVID‐19 in solid organ transplant recipients are only beginning to be understood with cases reported to date in transplant recipients on chronic immunosuppression. Herein, we report the first case of COVID‐19 in a lung transplant recipient in the immediate posttransplant period, and we describe the epidemiologic challenges in identifying the source of infection in this unique situation.

COVID-19, the clinical syndrome caused by the novel coronavirus, SARS-CoV-2, continues to rapidly spread, leading to significant stressors on global healthcare infrastructure. The manifestations of COVID-19 in solid organ transplant recipients are only beginning to be understood with cases reported to date in transplant recipients on chronic immunosuppression. Herein, we report the first case of COVID-19 in a lung transplant recipient in the immediate posttransplant period, and we describe the epidemiologic challenges in identifying the source of infection in this unique situation.

coronavirus, COVID-19, lung transplant Sixty hours after hospital admission, the donor was taken to the operating room for organ procurement following cardiac death. A repeat bronchoscopic examination revealed minimal airway secretions. Having met programmatic parameters for quality, the lungs were procured and prepared for transport ( Figure 1B ).

The recipient underwent bilateral sequential LT via thoracosternotomy with 86 minutes of cardiopulmonary bypass. The intraoperative course was without incident. Ischemic times for the right and left allografts were 246 and 335 minutes, respectively. Induction immunosuppression included intraoperative corticosteroids and basiliximab with a second basiliximab dose on postoperative day (POD) 4. Maintenance immunosuppression with mycophenolate mofetil (MMF) and corticosteroids was started immediately postoperatively, and tacrolimus, started on POD3, was titrated to a goal trough of 10-12 ng/mL. Four days of empiric antibiotics were administered per protocol and discontinued once intraoperative donor and recipient cultures finalized negative.

The patient was liberated from mechanical ventilation on POD1.

She developed worsening hypoxemia with extensive pulmonary edema on chest radiography, consistent with grade 3 primary graft dysfunction (Figure 2) , and was reintubated on POD2. On POD6, she became diaphoretic and febrile (39°C) with onset of atrial fibrillation/flutter.

Vancomycin and cefepime were started, but all cultures remained negative. Bronchoscopy on POD8 revealed airway inflammatory changes and purulent secretions. BAL bacterial and fungal cultures and multiplex respiratory viral panel were negative. Inflammatory markers were markedly elevated (Table 1) . Given concern for infection, MMF was decreased to 500 mg every 12 hours, and SARS-CoV-2 RT-PCR testing via nasopharyngeal swab (NPS) was obtained on POD9, returning positive 35 hours later. She was placed in droplet and contact precautions and transferred to a designated COVID-19 ward.

The patient's condition deteriorated with worsening oxygenation and hemodynamic instability requiring escalating doses of vasopressors. She developed acute kidney injury (AKI) requiring renal replacement therapy and atrial arrhythmias recurred, requiring amiodarone and cardioversion. Treatment with chloroquine and azithromycin was initiated on POD11. Remdesivir was contraindicated due to severe AKI; tocilizumab was considered, but not administered due to an unclear risk to benefit ratio in this recently transplanted patient. Prone positioning was considered although never implemented due to improving oxygenation with lung protective ventilation ( Figure 2 ). Following an initial period of vasopressor escalation, hemodynamics stabilized. On POD14, chloroquine was discontinued due to QTc prolongation and new data indicating lack of benefit. 6 MMF was discontinued, and the tacrolimus trough goal was decreased to 8 ng/mL.

Repeat SARS-CoV-2 RT-PCR testing via NPS on POD12 and POD14 was negative. The patient was transferred back to the cardiothoracic intensive care unit on POD28 and underwent tracheostomy on POD30. MMF was reinstituted on POD34 at 500 mg every 12 hours. As of POD57, she has been liberated from mechanical gram-specific variables must be taken into account.

We have described the epidemiological and treatment chal- 

First Cases of COVID-19 in heart transplantation from China

Case report of COVID-19 in a kidney transplant recipient: does immunosuppression alter the clinical presentation?

Successful recovery of COVID-19 pneumonia in a renal transplant recipient with long-term immunosuppression

Perioperative presentation of COVID-19 disease in a liver transplant recipient

COVID-19 in a lung transplant recipient

A pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (COVID-19)

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

https:// ishlt.org/ishlt /media /docum ents/SARS-CoV-2_-Guida nce-for-Cardi othor acic-Trans plant -and-VAD-cente rs

The authors recognize Jaime Schwartzwelder MT(ASCP), Smitha 

The authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation. NAM is a consultant for Abbott, Medtronic, SynCardia, and Carmat.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

https://orcid.org/0000-0003-2997-6712