key: cord-0933241-756v05ip authors: Arpali, Emre; Akyollu, Basak; Yelken, Berna; Tekin, Suda; Turkmen, Aydin; Kocak, Burak title: Case report: A kidney transplant patient with mild COVID‐19 date: 2020-05-04 journal: Transpl Infect Dis DOI: 10.1111/tid.13296 sha: 5ef5edbe4dee47c8210c8830b2e0398cf3e90d71 doc_id: 933241 cord_uid: 756v05ip Coronavirus Disease 2019 (COVID‐19) is currently a pandemic with a mortality rate of 1%‐6% in the general population. However, the mortality rate seems to be significantly higher in elderly patients, especially those hospitalized with comorbidities, such as hypertension, diabetes, or coronary artery diseases. Because viral diseases may have atypical presentations in immunosuppressed patients, the course of the disease in the transplant patient population is unknown. Hence, the management of these patients with COVID‐19 is an area of interest, and a unique approach is warranted. Here, we report the clinical features and our treatment approach for a kidney transplant patient with a diagnosis of COVID‐19. We believe that screening protocols for SARS‐Cov‐2 should be re‐evaluated in patients with solid‐organ transplants. complement deficiencies were detected in the context of her lupus-like syndrome. She had a kidney transplant with induction therapy of anti-thymocyte globulin and received triple maintenance therapy, which included oral tacrolimus (Tac), MMF, and prednisone (Pred). In the early period after the kidney transplant, she experienced a transient thrombotic microangiopathy induced likely by tacrolimus. She responded well to only two courses of Eculizumab treatment without any relapse. Since she had experienced intractable leukopenia while she was on triple maintenance, her immunosuppressive protocol was tailored to dual therapy early in the postoperative period, which consisted of tacrolimus and 10 mg Pred daily. The targeted tacrolimus level was determined to be between 6 and 8 ng/mL. During our first clinical evaluation, the patient's vital signs were within normal limits. The results of a physical examination of the heart, lungs, and abdomen were unremarkable. Only mild hyperemia of the tonsils and pharyngeal mucosa was noted as prominent findings. No other pathological findings were reported. Routine blood tests were run, and nasopharyngeal swab specimens were collected for influenza A/B, respiratory syncytial virus. Since, at our institution, the prerequisites for COVID-19 testing were a reported body temperature over 38°C or cough and/or respiratory distress and an epidemiologic risk of contact, no swabs were collected for COVID-19. According to the blood test results, the patient's creatinine level was 0.92 mg/dL, GFR was 85 mL/min, white blood cell count was 3120/µL, total lymphocyte count was 300/µl, hemoglobin level was 11,4 gr/dl, platelet count was 211 000/µL, and tacrolimus level was 7.23 ng/ml. However, her CRP level was slightly elevated, at 5.7 ng/L. No pathological findings were reported on chest x-ray. Her swabs tests were reported to be negative for influenza A/B. Amoxicillin was started empirically, and the patient was sent home with instructions for isolation. The following day, the patient presented to our transplant clinic with a high fever, which she measured as 38°C at home. The patient was transferred to the emergency department, and an infectious disease consultation was requested for COVID-19 testing. During this admission, the physical examination revealed a body temperature of 36.8°C, pulse rate of 70/min, respiratory rate of 14/min, blood pressure of 120/60 mm Hg, and oxygen saturation of 98% on room air. Physical examination findings were unremarkable, including breath sounds on chest auscultation. The blood test results were similar to those from the previous day. Swab tests for COVID-19 were collected, oseltamivir treatment was started empirically by the Infectious disease consultant, and she was discharged from the emergency department on the same day with very strict isolation instructions for home. Six days later, her swabs tests were reported to be positive for COVID-19. In the meantime, although she reported no high fevers or additional symptoms, the patient was admitted to the hospital for close monitoring and further testing. At the time of this admission, the patient had no complaints, and there were no positive physical examination findings suggesting a respiratory tract infection. A CT scan of the chest showed no pathological changes. All laboratory tests evaluating liver enzymes, kidney function, and acute phase reactants, including CRP, were within normal range except her total lymphocyte count, which was 800/µL. No change in vital signs or respiratory functions were observed during the 24-hour hospitalization for monitoring. She was discharged after 24 hours. Seven days after the discharge from the hospital she was seen in the clinic and swab tests were collected for COVID-19, which were reported to be negative afterward. To date, she has been healthy with no complaints at home for 14 days. et al also used hydroxychloroquine in addition to "lopinavir + ritonavir" or "darunavir + cobicistat"t treatment. They mentioned that the administration of colchicine may reduce the exaggerated inflammatory response observed in these patients. Unlike these previous cases, none of the five patients reported by Zhang et al were treated with hydroxychloroquine. Instead, their approach included supportive care and antiviral treatment of oseltamivir or arbidol. In addition, they did not reduce the immunosuppression in one of their patients. 14 Our review of the clinical courses revealed that most of the transplant patients were managed successfully without any progression of the disease. Only one transplant patient was lost due to quick respiratory deterioration before intubation.. 13 We did not discontinue our patient's immunosuppressive medication, because she was clinically stable and not critically ill. It is postulated that the over-activation of complement system or discordant expressions of type I and type II cytokines might lead to deficient viral clearance and exaggerated, prolonged inflammatory responses, which could result in a cytokine storm and the grave clinical course observed in coronavirus infections. 16, 17 Corticosteroids facilitate a reduction in systemic symptoms, such as fever or fatigue, and decrease alveolar exudation caused by the cytokine storm. 18 Colchicine may also alleviate this cytokine storm through a distinct pathway. 19 Therefore, we believe that strict precautions are necessary for contact isolation in transplant centers. The authors declare no conflicts of interest. Authors whose names are written above meet all of the four listed 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. Emre Arpali https://orcid.org/0000-0001-6172-2398 Clinical features of patients infected with 2019 novel coronavirus in Wuhan Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Clinical Characteristics of Coronavirus Disease 2019 in China Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study First Case of 2019 Novel Coronavirus in the United States Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro 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 COVID-19 in Kidney Transplant Recipients Identification of kidney transplant recipients with coronavirus disease 2019 Neutrophil-to-Lymphocyte Ratio Predicts Severe Illness Patients with Exacerbated Innate Host Response to SARS-CoV in Aged Non-Human Primates Complement activation contributes to severe acute respiratory syndrome coronavirus pathogenesis Corticosteroids as adjunctive therapy in the treatment of influenza: an updated cochrane systematic review and meta-analysis Severe acute respiratory syndrome coronavirus E protein transports calcium ions and activates the NLRP3 inflammasome