key: cord-349104-p0egfpx9 authors: Modi, Anita R.; Koval, Christine E.; Taege, Alan J.; Modaresi Esfeh, Jamak; Eghtesad, Bijan; Narayanan Menon, K. V.; Quintini, Cristiano; Miller, Charles title: Coronavirus disease 2019 in an orthotopic liver transplant recipient living with human immunodeficiency virus date: 2020-06-17 journal: Transpl Infect Dis DOI: 10.1111/tid.13351 sha: doc_id: 349104 cord_uid: p0egfpx9 Coronavirus disease 2019 (COVID‐19), mediated by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), can manifest with flu‐like illness and severe pneumonia with acute respiratory distress syndrome (ARDS). Immunocompromised patients merit particular attention as altered host immunity may influence both disease severity and duration of viral shedding as is described with several other ribonucleic acid respiratory viruses. Yet immunocompromised status alone, in the absence of other comorbidities, may not necessarily predict severe illness presentations and poorer clinical outcomes as indicated by recent reports of COVID‐19‐infected solid organ transplant recipients and people living with human immunodeficiency virus (HIV). Such patients may even be spared the robust inflammatory response that precipitates ARDS associated with COVID‐19, complicating the management of iatrogenic immunosuppression in this setting. We present a case of an orthotopic liver transplant recipient with well‐controlled HIV who successfully recovered from a mild, flu‐like illness attributed to SARS‐CoV‐2. ease severity and duration of viral shedding as is described with several other ribonucleic acid respiratory viruses. Yet immunocompromised status alone, in the absence of other comorbidities, may not necessarily predict severe illness presentations and poorer clinical outcomes as indicated by recent reports of COVID-19-infected solid organ transplant recipients and people living with human immunodeficiency virus (HIV). Such patients may even be spared the robust inflammatory response that precipitates ARDS associated with COVID-19, complicating the management of iatrogenic immunosuppression in this setting. We present a case of an orthotopic liver transplant recipient with well-controlled HIV who successfully recovered from a mild, flu-like illness attributed to SARS-CoV-2. COVID-19, HIV, hydroxychloroquine, immunocompromised, orthotopic liver transplantation Solid organ transplant recipients living with HIV uniquely demonstrate features of both immune suppression and immune activation, as evidenced by the increased rates of allograft rejection in such patients. 13 Definitive guidance on management strategies for COVID-19 in this specific population is lacking. We hope to contribute to the literature of COVID-19 in immunocompromised patients by describing an orthotopic liver transplant (OLT) recipient with well-controlled HIV who experienced a mild flu-like illness attributed to SARS-CoV-2. Our patient is a 32-year-old African American man diagnosed with HIV 10 years prior to presentation with a peak viral load of 107 000 copies/mL and a CD4 + T-cell count of 477 cells/µL. Efavirenz, emtricitabine, and tenofovir disoproxil fumarate were initiated at the time of diagnosis, and the patient rapidly achieved viral suppression. Two years after diagnosis, he suffered progressive liver failure attributed to antiretroviral-induced hepatotoxicity and underwent OLT in 2013. His maintenance immunosuppression consisted of mycophenolate mofetil (MMF), prednisone, and tacrolimus. His antiretroviral therapy (ART) was changed to raltegravir, emtricitabine, and tenofovir disoproxil fumarate post-transplantation. He experienced two episodes of biopsy-proven acute cellular rejection diagnosed two years and four years after OLT, treated with anti-thymocyte globulin. In March of 2020, five days after returning from a trip to New York City, he developed fatigue, fever, headache, and a dry cough. He presented to the emergency department and was found to have a temperature of 101 0 F. Nucleic acid amplification testing for influenza A, influenza B, and respiratory syncytial virus (Cepheid Xpert Xpress) performed on nasopharyngeal specimens was negative. Nucleic acid amplification testing for SARS-CoV-2 (Centers for Disease Control and Prevention, USA) performed on nasopharyngeal and oropharyngeal specimens was positive. He had been working at a community health center since his return, but reported no overtly ill contacts in that setting. The patient was initially instructed to engage in supportive care measures at home; however, the development of chest tightness and shortness of breath prompted presentation to the hospital the following day. He complained of aggravating dry cough, but denied any abdominal symptoms. His vital signs were within normal limits. Pertinent laboratory results are listed in Table 1 . Chest X-ray did not demonstrate any infiltrates. Computerized tomography (CT) imaging was not obtained. Given the patient's immunocompromised status and Interleukin-6 (pg/mL) TA B L E 1 Laboratory markers at baseline and throughout the clinical course of COVID-19 infection concern for symptom progression, he was admitted to the hospital despite his mild illness presentation. MMF was discontinued; prednisone was maintained, and tacrolimus was dosed to target a lower trough of 5-9 ng/mL. Hydroxychloroquine was administered outside of a clinical trial for five days. Antiretroviral therapy was continued. The patient's respiratory symptoms gradually improved, and he never demonstrated fever or hypoxia. He was discharged home on the sixth day of admission and instructed to maintain isolation for 14 days. Post-discharge laboratory testing demonstrated improved inflammatory markers and lymphopenia. Figure 1 depicts his clinical timeline. short-term liver transplant recipients were exposed to augmented immunosuppression including lymphodepleting agents more recently than their long-term counterparts, the short-term liver transplant recipients were significantly younger and healthier overall. 11 Our patient was transplanted seven years prior to diagnosis of COVID-19 and last received a lymphodepleting agent for the treatment of acute cellular rejection three years previously. Yet, his age and overall health more closely approximate those of the short-term liver transplant recipients included in this study. Immunosuppressive agents administered to solid organ transplant recipients compromise T-cell immunity responsible for viral recognition and eradication, thus prompting particular concern for the severity of the early and localized pulmonary phases of well-controlled HIV, successfully recovered from COVID-19. 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