key: cord-0943454-ofocdi7n
authors: Prieto, Mikel; Gastaca, Mikel; Ruiz, Patricia; Ventoso, Alberto; Palomares, Ibone; Rodr íguez-Álvarez, Regino José; Salvador, Patricia; Bustamante, Javier; Valdivieso, Andrés
title: A case of COVID-19 immediately after liver transplantation: Not only bad news
date: 2020-08-31
journal: Ann Hepatobiliary Pancreat Surg
DOI: 10.14701/ahbps.2020.24.3.314
sha: 88da512ac6c4610ce81dc64ec3e8173fdb619bae
doc_id: 943454
cord_uid: ofocdi7n

COVID-19, the illness caused by the SARS-CoV-2 virus originated in December 2019 in Wuhan, China and has caused more 3,3 million cases and more than 230,000 deaths throughout the world, with 25,000 of them only in Spain, where the first case was diagnosed on January 31st, 2020. As COVID-19 is a “new” disease, we still do not have data on prognosis or treatment in transplant patients or on how to manage immunosuppression in this complex scenario. We present a case of COVID-19 diagnosed during the early postoperative period in a recipient whose liver transplantation was performed on late March during the lockdown in Spain, with donor and recipient previously negative rRT-PCR to SARS-CoV-2. In the first post-operative week the patient suffered COVID-19 pneumonia that was treated with immunosuppression minimization, oral Hydroxycloroquine and Azithromycin with favorable outcome. The patient was discharged on POD 21 without complications. To date, few early post-liver transplantation SARS-CoV-2 infected recipients have been published, but only one was an early postoperative infection. In our case the outcome was favorable, even though it was an early post -liver transplantation COVID-19 in a frail patient.

The coronavirus disease-19 deaths. 1 In Spain, the first case was diagnosed on January 31st, 2020, and to date, up to 217,466 cases have been diagnosed with 25,264 deaths reported. 2 To date, Spain is the country with the second-highest number of confirmed COVID-19 cases. 1 In general population, 20% of COVID-19 patients develop severe illness requiring hospital admission. Moreover, 5% of patients need intensive care support, with a reported case fatality rate of 1-6% (11.6% in Spain). 2, 3 Patients under chronic immunosuppression such as liver transplantation recipients (LT) may present atypical respiratory infections, difficult to distinguish from other postoperative infections. 4 To date, few clinical experiences have been published on how SARS-CoV-2 affects immunosuppressed or transplant patients. [5] [6] [7] On the other hand, there are some data among surgical patients with postoperative COVID-19 infection, 44.1% requiring Intensive Care Unit (ICU) with a mortality rate approaching 50%, 8 reflecting a much more higher ICU admission and mortality rates than non-surgical COVID19 patients. 3 Lei et al. 8 suggest that surgery may accelerate and exacerbate disease progression of COVID-19.

To date, only one case of early postoperative COVID-19 disease has been described in LT. 9 We present a case of COVID-19 diagnosed during the early postoperative period in a recipient whose LT was performed at the end of March during the lockdown in Spain.

The liver recipient was a blood group A positive 52- The patient was discharged on POD 21 without further complications (Fig. 2 ).

Severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) were reported in transplant recipients during prior outbreaks of these viruses. 14 Although it is not yet known if immunosuppression is a risk factor for more severe disease, the transplant community eagerly awaits more studies in this patient population. 6 The first two reported cases of solid organ transplantation (SOT) with COVID-19 were two heart transplant recipients from the city of Wuhan (Hubei, China). 15 To date, few clinical cases of LT with COVID-19 8, 9, 16, 17 and three series from Italy and USA with small number 7, 18, 19 have been published and only one was an early infection just after LT. 8 Recently, the first COVID-19 related death after LT has been reported. 17 In our case, even though it was an early post-LT COVID-19 in a frail patient, a favorable outcome was observed.

As SARS-CoV-2 rt-PCR was negative for both donor and recipient, we decided to initiate intravenous broad-spectrum antibiotic therapy. The MMF dose had already been It is known that in these initial stages, symptoms can be mild and non-specific; however, chest imaging may reveal bilateral infiltrates or ground glass opacities as, in our case. 21 phased approach to decrease transplant activity has been recommended. 23 In Spain a dramatic decrease in organ donation has been observed: from a mean of 15-18.6 donors per day in the first months of 2020 to a mean of 0.3-1.4 donors per day during the lockdown period. 10 In conclusion, although liver recipients could be considered as potentially high-risk patients, favorable outcomes could be achieved even in case of postoperative COVID- 19 infection, provided that a quick diagnosis is made.

The fact that immunosuppressive state could be protective in severe COVID-19, as proposed by some authors, needs to be proved.

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