Blake Primi, MD,
Critical Care Medicine Fellow
University of Colorado School of Medicine
Aurora, CO
Disclosure information not submitted.
Jacob Basak, MD, PhD
Assistant Professor
University of Colorado School of Medicine
Aurora, Colorado, United States
Disclosure information not submitted.
Title: A Case of Suspected COVID-19 Reactivation in a Kidney Transplant Recipient
Case Report Body:
Introduction: Transplant recipients treated with immunosuppressive agents are known to be vulnerable to reactivation of viruses. It is presently unknown whether SARS-CoV-2 can reactivate and cause recurrent COVID-19. Here we describe a case of suspected SARS-CoV-2 reactivation in a patient who underwent kidney transplantation.
Description: A 54 year-old man with a history of COVID-19 (from which he recovered two months prior) and end-stage renal disease secondary to focal segmental glomerulosclerosis was admitted for deceased donor kidney transplant. He underwent transplantation and induction with rabbit anti-thymocyte globulin (rATG). The patient became acutely hypoxic and profoundly hypotensive toward the end of the surgery requiring the initiation of epinephrine, norepinephrine, and vasopressin infusions. He was transferred to the intensive care unit intubated and still on vasopressors. The patient was then started on tacrolimus, mycophenolate mofetil, and corticosteroids to prevent graft rejection. Overnight, his oxygen requirements continued to rise, and the patient’s chest radiograph revealed a new retrocardiac opacity. He was tested again for COVID-19 via polymerase chain reaction and it returned positive (confirmed with a second assay). This result was unexpected as the patient had tested negative twice prior to admission and reported no symptoms in the preoperative assessment. On postoperative day one he had already begun to develop ischemic hepatitis that prohibited treatment with remdesivir, so he was treated for COVID-19 with convalescent plasma. Unfortunately, the patient continued to deteriorate with multisystem organ failure, and on postoperative day 10 his family elected to withdraw care.
Discussion: The ability of SARS-CoV-2 to lie quiescent and reactivate remains unknown but is postulated to occur with sparse cases being reported. What is known, however, is that constant host immune surveillance by T lymphocytes can prevent reactivation of latent viral infections. Additionally, T lymphocytes play a pivotal role in COVID-19 immunity, and anti-rejection medications such as rATG rapidly deplete these vital cells. Caution with immunosuppressive agents—particularly those targeting lymphocytes—must be exercised in patients with recent COVID-19 infection while further research is conducted.