Early acute rejection after lung transplantation mimicking viral pneumonia in the middle of COVID-19 pandemic: A case report

Alessandro Palleschi; Lorenzo Rosso; Letizia Corinna Morlacchi; Alessandro Del Gobbo; Miriam Ramondetta; Andrea Gori; Francesco Blasi; Mario Nosotti

doi:10.1016/j.ijscr.2020.10.105

Early acute rejection after lung transplantation mimicking viral pneumonia in the middle of COVID-19 pandemic: A case report

Int J Surg Case Rep. 2020:77:80-85. doi: 10.1016/j.ijscr.2020.10.105. Epub 2020 Oct 28.

Authors

Alessandro Palleschi¹, Lorenzo Rosso², Letizia Corinna Morlacchi³, Alessandro Del Gobbo⁴, Miriam Ramondetta⁵, Andrea Gori⁶, Francesco Blasi⁷, Mario Nosotti²

Affiliations

¹ Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy; University of Milan, Italy. Electronic address: alessandro.palleschi@unimi.it.
² Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy; University of Milan, Italy.
³ Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy.
⁴ Pathology Unit, Center - Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy.
⁵ North Italy Transplant Program (NITp), Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy.
⁶ University of Milan, Italy; Infectious Diseases Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy.
⁷ University of Milan, Italy; Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy.

Abstract

Introduction: In addition to morbidity and mortality rate per se, COVID-19 outbreak leads to potential 'side effects', which are difficult to evaluate and predict. Lung transplantation is a consolidated treatment for end-stage chronic lung disease requiring significantly demanding management. Deciding whether to keep transplant programmes open during an epidemic of this size is not easy, as immunosuppressed subjects face the risk of infection and related mortality. Additionally, there is a chance for the patient's standard care process to be compromised.

Presentation of case: We report the case of a patient undergoing bilateral lung transplantation during the explosion of COVID-19 epidemic in Lombardy; he died from definite early acute antibody-mediated rejection, clinically (persistent high fever, unresponsive to treatment) and radiologically mimicking viral pneumonia but persistently negative for SARS-CoV-2.

Discussion: The diagnosis was difficult given this atypical presentation, confounded by global scenario. Grafts were procured from a donation after circulatory death donor in an uncontrolled setting and a donor-recipient transmission was possible. Our institute became a COVID-Hospital right during the first post-transplantation days. Radiological imaging had the same features of SARS-CoV-2 pneumonia.

Conclusions: This is the first report of lung transplantation of the COVID-19 era in Europe. Our extremely fragile patient was COVID-19 free up to the end. Donor-recipient transmission is conceivable, but the risk should be assessed with respect to waiting list mortality. Ultimately, treating COVID-19 patients can be a resource-consuming activity but we decided to keep our centre open.

Keywords: AMR, antibody-mediated rejection; Acute antibody-mediated rejection; BAL, bronchoalveolar lavage; COVID-19; CT, computed tomography; Case report; DCD, donation after circulatory death; DSA, donor-specific antibodies; Donation after circulatory death donor; FiO2, fraction of inspired oxygen; ICU, intensive care unit; Lung transplantation; NIV, non-invasive ventilation; PCR, polymerase chain reaction; POD, post-operative day; PaO2, partial arterial oxygen pressure; SARS-CoV-2.

Publication types

Case Reports