Introduction
The first case of infection from the novel coronavirus, SARS-CoV-2, named Coronavirus disease 2019 (COVID-19), was identified in Wuhan, China, in December 2019 and has become a pandemic; the COVID-19 infection is characterized by respiratory disease (1). COVID-19 has been reported to have a higher fatality rate and a more severe clinical course than other viral respiratory diseases, particularly in the elderly and those with comorbidities (2). Although patients can be asymptomatic or present either mild flu-like symptoms or severe upper respiratory tract infection, cases of severe viral pneumonia with respiratory failure have been encountered (3-5).
Severe clinical conditions have been reported in solid organ transplant (SOT) recipients owing to immunosuppression, and chronic immunosuppression has been shown to be a highly comorbid condition. Varying clinical results have been reported from China, Italy, and France for COVID-19 in SOT recipients on different immunosuppressive modalities (6-10). We aimed to present a fatal case of COVID-19 in kidney transplant recipient.
Case Report
A 47-year-old man who had undergone living-donor kidney transplantation at another hospital 8 years ago, presented to a health center with the complaints of fever, malaise, and cough, where COVID-19 was suspected and laboratory and thoracic computed tomography (CT) examinations were performed. The patient was referred to our clinic, which is a pandemic and organ transplantation center. The patient had fever (38.7 °C), malaise, and cough on presentation. Lung examination revealed bilateral diffuse coarse rales. His O2 saturation was 92%, heart rate was 125/min, and respiratory rate was 24/min. The immunosuppression protocol of the patient was as follows: sirolimus (Rapamune) 2 × 1 mg, mycophenolate mofetil (MMF) 2 × 500 mg, and steroid 1 × 5 mg. In addition, he was administered amlodipine 10 mg as an antihypertensive. His medical records showed that he primarily had renal amyloidosis because of familial Mediterranean fever. The patient was followed-up at our clinic 1 month prior, when he had a creatinine level of 2.67 ng/mL, and the graft biopsy performed approximately 1 year ago presented signs of chronic allograft nephropathy.
On hospitalization day 1, the patient’s creatinine, C-reactive protein, and procalcitonin levels were 3.57 ng/mL, 70 mg/L, and 0.14 ng/mL, respectively, and his leukocyte and absolute lymphocyte counts were 5700/µL and 1000/µL. His sirolimus level was 7.5 ng/mL.
Thoracic CT showed involvement consistent with bilateral diffuse viral pneumonia (Figure 1).
According to the COVID-19 Treatment Protocol of the Ministry of Health, the patient was initiated on oseltamivir 2 × 75 mg, hydroxychloroquine 2 × 200 mg, and azithromycin 1 × 500 mg. On the third day of treatment, he developed severe respiratory distress, with decreased O2 saturation of 83%. He was transferred to the intensive care unit, wherein he was intubated. We halved the MMF dose, and initiated favipiravir 2 × 600 mg; however, on hospitalization day 9, the patient died. Table 1 summarizes the patient’s laboratory examination results, clinical course, and treatment details.
The patient’s PCR tests on hospitalization days 1 and 3 were negative for COVID-19. However, a PCR test conducted with the bronchoalveolar lavage sample collected from the endotracheal tube on hospitalization day 5 was positive for COVID-19.
Discussion
The clinical course of our patient, who was an SOT recipient and contracted COVID-19, deteriorated rapidly, leading to mortality.
While COVID-19 pneumonia may not manifest typically a severe infection, it could lead to severe infection or even mortality in immunosuppressed patients, as in our case (11).
The study by Aslam and Mehra (12) that included 2 heart transplant recipients with COVID-19 reported the death of 1 patients because of severe pneumonia.
A study from China reported the different clinical courses of 2 heart transplant recipients with COVID-19, with 1 requiring prolonged hospitalization (39 days); however, both patients recovered (12).
Several case reports of SOT recipients contracting COVID-19 continue to be reported globally, with presentations ranging from mild to severe (13).
Although viral infections are known to have a fatal course in transplant patients, age, sex, and comorbidities are important predictor of the course of COVID-19 in these patients. In addition to immunosuppression, hypertension and chronic allograft nephropathy were likely significant comorbidities in our patient; however, as is shown in the study by Liu et al. (14), lymphopenia and increased D-dimer levels from admission to death were important indicators of the poor clinical course.
Conclusion
In conclusion, we present a case of COVID-19 in a renal transplant recipient that resulted in mortality. However, several reports of mild infection in SOT recipients with COVID-19 exist. Hence, larger-scale studies are needed to conclusively determine the risk factors. The clinical of COVID-19 could be unpredictable in immunocompromised patients and hence, it should be tested for in all transplant patients.
Ethics
Peer-review: Externally peer-reviewed.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.