key: cord-0997456-2plv75os
authors: Russell, Matthew R.; Halnon, Nancy J.; Alejos, Juan C.; Salem, Morris M.; Reardon, Leigh C.
title: COVID-19 in a pediatric heart transplant recipient: Emergence of Donor Specific Antibodies
date: 2020-04-29
journal: J Heart Lung Transplant
DOI: 10.1016/j.healun.2020.04.021
sha: 42e5095f913b7fb3864ae37276005cb3cde9ad24
doc_id: 997456
cord_uid: 2plv75os

nan

Early reports have suggested severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated coronavirus disease 2019 (COVID-19) generally causes mild disease in children. 1 Pediatric solid organ transplant recipients are generally more susceptible to viral respiratory infections and have increased morbidity and mortality. 2 There have been limited reports of COVID-19 disease in heart transplant recipients.3 A 3-year-old female underwent an orthotopic heart transplant at 11 months-of-age for congenital dilated cardiomyopathy in late 2017. Her post-transplant course had been unremarkable except for persistent Ebstein Barr Virus (EBV) viremia for which the intensity of immunosuppression had been reduced to tacrolimus monotherapy. In the first week of March 2020 the patient developed a productive cough with rhinorrhea and nasal congestion. She was afebrile with no symptoms of shortness-of-breath. A month prior to this illness she was treated for febrile bronchiolitis as an outpatient. Potential for COVID-19 disease was considered but community incidence was low at the time, the patient had no Center for Disease Control risk factors for infection, and testing was not widely available. One-week later a follow-up telehealth visit was performed with improvement in severity of cough and she remained afebrile. Surveillance laboratory studies including complete blood count, EBV whole blood DNA, and anti-human leukocyte antigen antibody testing by Luminex assay happened to be performed at that time. were deferred and patient eventually discharged. Repeat SARS-CoV-2 nasal PCR was planned for two weeks with repeat anti HLA antibody testing and IVIG administration repeated every month for two more months.

This patient notably was receiving tacrolimus monotherapy at the time of infection due to persistent EBV viremia and therefore may have mounted a more efficient immune response than if she had additionally been receiving an antimetabolite or corticosteroid. In vitro data suggest inhibition of viral replication of human coronaviruses by FK-506. 4 Interestingly, de novo donor specific Class II antibodies also were detected during the infection. Allosensitization following viral infections is described and due to the reduced amount of immunosuppression our patient may have been prone to this phenomenon. 5 This patient tolerated IVIG administration with concurrent COVID-19 infection without any notable reaction. We would be hesitant to attempt more aggressive forms of desensitization with active infection until more clinical knowledge of COVID-19 infection is available. Although mechanisms and relationship between allosensitization and COVID-19 remain uncertain, we suggest careful measurement of donor specific antibodies be undertaken in heart transplant survivors of this infection.

Disclosures: The authors have no disclosures to report.

Screening and Severity of Coronavirus Disease 2019 (COVID-19) in Children in

Respiratory Viral Infections in Solid Organ and Hematopoietic Stem Cell Transplantation

First Cases of COVID-19 in Heart Transplantation From China

Replication of human coronaviruses SARS-CoV, HCoV-NL63 and HCoV-229E is inhibited by the drug FK506

Infectious pathogens may trigger specific allo-HLA reactivity via multiple mechanisms

Funding sources: None