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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 335-337

Heart transplant recipient with features of COVID-19 infection: First case report from India


Department of Cardiothoracic and Vascular Surgery, SMS Medical College and Attached Hospitals, Jaipur, Rajasthan, India

Date of Submission23-May-2020
Date of Acceptance04-Oct-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Dhruva Sharma
Department of Cardiothoracic and Vascular Surgery, SMS Medical College and Attached Hospitals, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_48_20

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  Abstract 


A 16-year-old boy has been reported 3 months postcardiac transplantation with chief complaints of nausea, vomiting, pain in abdomen, and fever. The patient had remarkably increased serum lactate dehydrogenase levels, triglycerides, serum amylase, and serum lipase. The B-type natriuretic peptide level more than 35,000 ng/mL and troponin T was increased (0.57 μg/ml). Last known concentration of tacrolimus was 9 ng/ml. Supraventricular tachycardia was remarkable on electrocardiogram. His computed tomographic findings revealed bilateral pneumothorax with bilateral pleural effusion with an opacity seen in the right upper lobe. Bedside echo revealed dilated right atrium and right ventricle with left ventricular ejection fraction of 60%. He was kept on immunosuppression of mycophenolate mofetil 360 mg (2 tablets twice a day) and tacrolimus (2.5 mg twice a day). His reverse transcriptase-polymerase chain reaction throat swabs of the patient were sent for testing 2019-nCoV and were found to be negative. The patient could not be revived in spite of all medical management.

Keywords: B-type natriuretic peptide, cardiac transplantation, COVID-19 infection, troponin T


How to cite this article:
Sharma D, Dixit S, Sharma A. Heart transplant recipient with features of COVID-19 infection: First case report from India. Indian J Transplant 2020;14:335-7

How to cite this URL:
Sharma D, Dixit S, Sharma A. Heart transplant recipient with features of COVID-19 infection: First case report from India. Indian J Transplant [serial online] 2020 [cited 2021 Apr 11];14:335-7. Available from: https://www.ijtonline.in/text.asp?2020/14/4/335/305427




  Introduction Top


The intercontinental pandemic of coronavirus disease 2019 (COVID-19) has quirky inference for cardiothoracic surgeons including those on waiting list and recipients of heart transplantation. These patients are at upsurged risk of possession of COVID-19 infection which may be life-threatening. High prevalence of cardiovascular disease among infected patients is documented, and >7% of patients are announced to experience myocardial injury due to COVID-19 infection.[1],[2]

Manifestations of myocarditis specifically in heart transplant recipients with elevated levels of troponin levels, changes in electrocardiogram, and new left ventricular (LV) dysfunction might be mistaken for rejection. In this case report, we will be delineating about a young boy who came 3 months postcardiac transplant with the features of COVID-19 infection and could not be revived during coronavirus pandemic.


  Case Report Top


A 16-year-old boy has been reported 3 months postcardiac transplantation with chief complaints of nausea, vomiting, and pain in the abdomen for 1 day along with 1 episode of fever for 3 days. At the time of admission, he was tachycardiac and hypotensive with hyperpnea. His jugular venous pulse was normal. His dorsalis paedis artery and posterior tibial artery were not felt; however, his extremities were not cold and clammy.

Generalized abdominal tenderness, guarding, and rigidity were present. Immediately venous access in peripheral vein was taken and correction of arterial blood gas was done. Triple-lumen neck line insertion was done. Ryle's tube was inserted, and 300 ml of bilious fluid was aspirated.

After correcting hyponatremia and acidosis, he was put on supportive medical management. Vasopressin was started immediately. Oxygen saturation was corrected by nasal prongs at the rate of 4 L/min.

His Vitamin D levels were reduced (12.73 ng/ml), whereas serum ferritin levels were markedly raised (899.3 ng/ml). He was found positive for C-reactive protein (CRP = 385 mg/L. His erythrocyte sedimentation rate was found to be 50. The patient had remarkably increased serum lactate dehydrogenase (LDH) levels, triglycerides, serum amylase, and serum lipase. His urine examination revealed high levels of urea and creatinine; however, serum calcium, total proteins, albumin, and globulins levels were reduced. The B-type natriuretic peptide level more than 35000 ng/mL and troponin T was increased (0.57 μg/ml). Last known concentration of tacrolimus was 9 ng/ml. The patient underwent hemodialysis through right internal jugular vein as per suggested by nephrologists. He was HBsAg and anti-hepatitis C virus negative. His ultrasonographic findings were unremarkable. X-ray demonstrated minimal left-sided pneumothorax. Supraventricular tachycardia was remarkable on electrocardiogram, as depicted in [Figure 1].
Figure 1: Electrocardiogram of the case showing predominant supraventricular tachycardia

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His chest-computed tomographic (CT) findings revealed moderate right hydropneumothorax with mild left pleural effusion. There was a partial collapse of underlying bilateral lung field. There were multiple ill-defined patches of air space opacification with few air bronchograms as seen in bilateral lung fields, more marked in right upper and lower lobes suggestive of multifocal consolidation. Few fibrotic bands were appreciated with multiple enlarged pretracheal, paratracheal, and subcarinal group of lymph nodes (largest measure 15 cm × 12 cm) [Figure 2]. These features were suggestive of COVID-19 infection.[3] CT whole abdomen findings were unremarkable ruling out gastrointestinal diagnoses.
Figure 2: Chest computed tomographic film showing right pneumothorax with mild left pleural effusion with multiple ill-defined patches of air space opacification with few air bronchograms as seen in bilateral lung fields. More marked in the right upper and lower lobes suggestive of multifocal consolidation

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Bedside echo revealed dilated right atrium and right ventricle with left ventricular ejection fraction (LVEF) of 60%. He had mild-to-moderate tricuspid regurgitation with right atrial pressure of 30+. He was kept on the immunosuppression of mycophenolate mofetil 360 mg (2 tablets twice a day) and tacrolimus (2.5 mg twice a day). His reverse transcriptase–polymerase chain reaction throat swabs of the patient were sent for testing 2019-nCoV, were found to be negative. The patient was afebrile and settled on the next day. All the peripheral pulses were palpable. Vasopressin was tapered, but the patient became tachycardiac (heart rate = 200 beats/min) and hypotensive, so escalation of vasopressin was done, and tablet ivabradine was administered.

On the 2nd day of readmission, he had bilateral basal crepts with edematous face and body. He was initiated on injectable meropenem 1 g and injection aztreonam 500 mg intravenous (IV), injection methyl prednisolone 4 mg IV, along with symptomatic medical management. Dose modifications of immunosuppressants and changes in drug regimen were performed as advised by nephrologist. Leukocytopenia was predominant on blood examination, for this filgrastim was administered (300 μg SC). The patient underwent hemodialysis through right internal jugular vein 500 ml ultrafiltrate taken. He developed nasal bleed at night which was managed with local packing of the nose. The patient could not be revived and died. At the time of death, the throat swab was sent for COVID testing, which came negative.


  Discussion Top


There has been an increase in the number of heart transplant recipients in the recent past.[4] Solid-organ transplant recipients are kept under chronic immunosuppression which leads to the atypical presentation of respiratory infections among such patients.

The findings of our case corroborate with the findings of first heart transplant cases with COVID-19 reported from China. First case was 51-year-old heart transplant recipient who was kept on the immunosuppression of tacrolimus 1 mg twice daily plus mycophenolate mofetil 0.5 g twice daily. He also came with similar gastrointestinal complaints almost 17 years postcardiac transplantation. He was treated with IV human gamma globulin 10 g/day and methylprednisolone 80 mg/day for 5 consecutive days. Another 43-year-old male patient came with fever and mild CT findings. His nucleic acid test for 2019-nCoV was positive. Both the patients were discharged with a negative nucleic acid test for 2019-nCoV.[5]

Due to multiple comorbidities, heart transplant recipients are at increased risk of adverse outcomes of COVID-19 infection. Another case series of 26 patients of COVID-infected heart transplant recipients was reported from New York.[6]

Succeeding cardiac transplantations, momentous complications entailing the alimentary tract are commonly reported, and may be connected with noteworthy morbidity and mortality.[7] It was observed in previous studies that, hs-cTnI was found >99th percentile upper reference limit in 46% of nonsurvivors as compared to 1% of survivors.[8] There may be associated cytokine storm manifested by the increased levels of interleukin-6, ferritin, LDH, and D-dimer leading to myocardial injury.

In spite of elevated B-type natriuretic peptide level and troponin T values, the LVEF of the patient was 60%, and there was no right-sided heart failure, so it ruled out acute rejection. This case suggested that a patient with high clinical suspicion of COVID-19 with the COVID-19 Reporting and Data System[9] category-4, but multiple negative reverse transcriptase-polymerase chain reaction (RT-PCR) result should not be taken out of quarantine. A consolidation of patient's history of exposure, clinical manifestations, laboratory tests, and typical imaging findings play an indispensable role in making preliminary diagnosis and guide early isolation and treatment. Repeated COVID-19 testing will be helpful in the diagnosis for this kind of patients. However, in our case, the patient could not make up and died, so further testing could not be done.[10] Although pleural effusion is not the usual presentation for COVID-19 infection as we found in our case, it should not be ignored because it has been concluded as one of the sign of corona infection.[3],[11],[12]


  Conclusions Top


Similar presentation of heart transplant recipients with general population was demonstrated in the past epidemics of coronaviruses such as Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS). A strong crucial suspicion is mandatory in heart transplant recipients with the findings of coronavirus infection even if COVID-19 RT-PCR test comes negative. Due to high fatality among these patients, a close monitoring is mandated.

Declaration of patient consent

The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patient understands that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. COVID-19 and cardiovascular disease. Circulation 2020;141:1648-55.  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
Carotti M, Salaffi F, Sarzi-Puttini P, Agostini A, Borgheresi A, Minorati D, et al. Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: Key points for radiologists. Radiol Med 2020;125:636-46.  Back to cited text no. 3
    
4.
Ezhumalai B, Rao S, Balakrishnan KR. Triple ECMO therapy and emergency PCI performed perioperatively during pediatric heart transplantation.IHJ Cardiovascular Case Reports (CVCR) 2019;3:4-6.  Back to cited text no. 4
    
5.
Li F, Cai J, Dong N. First cases of COVID-19 in heart transplantation from China. J Heart Lung Transplant 2020;39:496-7.  Back to cited text no. 5
    
6.
Latif F, Farr MA, Clerkin KJ, Habal MV, Takeda K, Naka Y, et al. Characteristics and outcomes of recipients of heart transplant with coronavirus disease 2019. [published online ahead of print, 2020 May 13]. JAMA Cardiol. 2020;e202159. doi: 10.1001/jamacardio. 2020.2159  Back to cited text no. 6
    
7.
Stefaniak T, Głowacki J, Dymecki D, Lachinski A, Gruca Z. Pancreatitis following heart transplantation: Report of a case. Surg Today 2003;33:693-7.  Back to cited text no. 7
    
8.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 8
    
9.
Prokop M, van Everdingen W, van Rees Vellinga T, Quarles van Ufford H, Stöger L, Beenen L, et al. CO-RADS: A categorical CT assessment scheme for patients suspected of having COVID-19-definition and evaluation. Radiology 2020;296:E97-E104.  Back to cited text no. 9
    
10.
Chen LD, Li H, Ye YM, Wu Z, Huang YP, Zhang WL, et al. A COVID-19 patient with multiple negative results for PCR assays outside Wuhan, China: A case report. BMC Infect Dis 2020;20:517.  Back to cited text no. 10
    
11.
Ahmadinejad Z, Salahshour F, Dadras O, Rezaei H, Alinaghi S. Pleural Effusion as a Sign of Coronavirus Disease 2019 (COVID-19) Pneumonia: A Case Report. Infect Disord Drug Targets. 2020 Jun 9. doi: 10.2174/1871526520666200609125045. Epub ahead of print. PMID: 32516107.  Back to cited text no. 11
    
12.
Hong-Rui C, Hao Z, Mei X, Zhen-Bing C, Wan-Xin C. A case of childhood COVID-19 infection with pleural effusion complicated by possible secondary mycoplasma pneumoniae infection. The Ped Infect Dis J 2020;39:e135-7.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Mycophenolate mofetil/tacrolimus
Reactions Weekly. 2021; 1847(1): 357
[Pubmed] | [DOI]



 

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