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Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 363-365

Co-infection of COVID-19 with dengue fever and acute graft dysfunction in a kidney transplant recipient - A case report

1 Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Nephrology, Patna Medical College; Department of Internal Medicine, AIIMS, Patna, Bihar, India

Date of Submission19-Aug-2020
Date of Acceptance25-Nov-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Prit Pal Singh
Department of Nephrology, Room No. 14, First Floor, Old Administrative Building, Indira Gandhi Institute of Medical Sciences, Patna - 800 014, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_104_20

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Among coronavirus disease 2019 (COVID-19) pandemic, endemic infections also peak in India during this monsoon. Kidney transplant recipients are at higher risk of contracting infections with increased morbidity and mortality. Co-infection of COVID-19 with other infections is apprehended with more unfavorable outcome. We report a case of young renal allograft recipient with co-infection of COVID-19 and dengue fever presenting with acute graft dysfunction. Apart from supportive treatment and reduction in immunosuppressants, the patient was managed with dexamethasone, remdesivir, and heparin. The patient responded to the treatment and graft dysfunction improved on conservative management. This case emphasizes the need to consider endemic diseases also during workup of COVID-19 patients and shows that co-infections even with acute graft dysfunction can also have favorable prognosis. This case also points out the difficulties faced in managing immunosuppressants due to fear of acute graft rejection.

Keywords: Acute graft dysfunction, co-infection, COVID-19, dengue, kidney transplant recipient

How to cite this article:
Krishna A, Singh PP, Vardhan H, Kumar O. Co-infection of COVID-19 with dengue fever and acute graft dysfunction in a kidney transplant recipient - A case report. Indian J Transplant 2020;14:363-5

How to cite this URL:
Krishna A, Singh PP, Vardhan H, Kumar O. Co-infection of COVID-19 with dengue fever and acute graft dysfunction in a kidney transplant recipient - A case report. Indian J Transplant [serial online] 2020 [cited 2021 May 14];14:363-5. Available from: https://www.ijtonline.in/text.asp?2020/14/4/363/305420

  Introduction Top

India is among the countries, worst hit by novel coronavirus disease 2019 (COVID-19) pandemic and has reported >2.6 million cases and 50,000 deaths till date.[1] Along with ongoing pandemic, the incidence of endemic vector-borne infections such as dengue and malaria are also on the peak during this monsoon season. COVID-19 is caused by “severe acute respiratory syndrome coronavirus 2” of coronaviridae family and dengue is caused by an arbovirus of Flaviviridae family. Kidney transplant recipients are at heightened risk of infections due to lifelong administration of immunosuppressants.[2],[3],[4] If transplant recipients contract more than one infection at a time, morbidity and mortality are apprehended to be higher. We are reporting a case of COVID-19 with co-infection of dengue fever and acute graft dysfunction in kidney transplant recipient.

  Case Report Top

A 28-year-old married female who received a live kidney donation from her mother 4 years ago presented with complaints of malaise and body ache for 5 days, high-grade fever and sore throat for 3 days, headache with nausea for 2 days, and breathlessness for 1 day. This was not associated with lower urinary tract symptoms, pain abdomen, and hematuria or decreased urine output.

She had a history of acute cellular graft rejection BANFF Class I B, 3 months after transplantation and was treated with five doses of injection (Inj.) methylprednisolone (500 mg). Serum creatinine settled to 1.50 mg/dl and remained stable thereafter.

On evaluation, her body temperature was 103.4°F, heart rate 126/min and regular, blood pressure 110/70 mmHg, respiratory rate was 28/min and oxygen saturation (SpO2) at room air was 90%. Systemic examination was unrevealing. Based on our protocol, she was categorized to have moderately severe disease and was admitted in COVID designated high dependency unit under one of the authors. Symptomatic management was started and mycophenolate mofetil (MMF) was withheld. The relevant investigations are given below [Table 1].
Table 1: The important investigations of our patient

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She maintained SpO2 above 95% at oxygen supplementation of 6–8 l/min by venturi mask. Along with supportive measures, she was administered azithromycin 500 mg, Injection. remdesivir, subcutaneous injection enoxaparin 40 mg, and injection dexamethasone 6 mg. Prednisolone was withheld and tacrolimus was reduced by 25%. The patient improved gradually, became afebrile, and was able to maintain SpO2 of more than 95% on room air by the 6th day. Remdesivir, azithromycin, and LMWH were discontinued after 5 days. Dexamethasone was replaced by prednisolone. The patient was subsequently discharged with advice of isolation and self-monitoring at home for the next 7 days.

  Discussion Top

Many transplant recipients have been affected with COVID-19 worldwide with increased morbidity and mortality.[4] Moreover in tropics, simultaneously endemic infections and COVID-19 may occur and one infection can masquerade signs and symptoms of others. In this report, we discussed one such case of co-infection with both COVID-19 and dengue fever.

Symptoms such as fever, malaise, profound weakness, and body aches are common in both COVID-19 and dengue fever, making initial diagnosis challenging. With fever, sore throat, and dyspnea, patient's presentation was highly suggestive of COVID-19 infection. However, the patient also had a disproportionate headache, retro-orbital pain, and arthralgia suggesting another co-existing pathology such as dengue fever as it is hyperendemic in our region, especially during the rainy season. In this patient, dengue would have been easily missed if it was not thought of and investigated. Our patient also had acute graft dysfunction following infection which improved on conservative management and was most likely due to the concurrent infections. Acute kidney injury has been reported in COVID-19 and dengue infection as well.[2],[4]

Azevedo et al.[5] in their study concluded that dengue in kidney transplant recipient is a benign condition without any long-term impact on patient or graft survival while a study from India by Prasad et al.[2] has indicated that dengue fever in transplant recipient is associated with unacceptably high mortality. This may be explained by the fact that a large number of cases may be asymptomatic or with mild flu-like symptoms hence missed.[6] Our patient did not develop thrombocytopenia or any other feature of severe dengue or dengue shock syndrome which is associated with poor outcome. Hence, we prioritized the management of COVID-19 related issues and kept watch on the appearance of any symptom or sign of severe dengue.

The treatment strategy and management of immunosuppressants in kidney transplant recipient with COVID-19 is not yet clear. While Alberici et al.[4] totally withdrew both MMF and tacrolimus in their patients; Akalin et al.[7] withdrew only antimetabolites in 86% and tacrolimus in 21% of cases. Following the diagnosis in our case, MMF was totally withdrawn and dose of tacrolimus was reduced. Younger age and history of ACR are known risk factors for graft rejection and the unusual high risk of graft rejection in COVID pandemic as shown by Aziz et al.;[8] we did not follow protocol suggested by Alberici et al.

Hydroxychloroquine was not used as tacrolimus and azithromycin were used both of which may increase QT interval and substantial benefit has not been proven.[9],[10]

Remdesivir or favipiravir have shown some benefit in COVID-19 patients and are being used on experimental or compassionate basis. Large multinational trials such as the phase III-IV SOLIDARITY and RECOVERY trials may soon provide the answer.[9],[10] Along with supportive treatment, dexamethasone, and remdesivir were used as an experimental drugs that may be of some value in moderate-to-severe cases.[9] The patient did not develop severe dengue or severe COVID-19, gradually improved and made an uneventful recovery from both diseases.

  Conclusion Top

Our case report suggests that the possibility of co-infection with other endemic diseases should always be considered in this COVID-19 pandemic period. Despite reports of adverse outcome with COVID-19 in transplant patients, even co-infections with acute graft dysfunction can also have favorable prognosis if we remain vigilant. Real challenge among transplant recipients is managing immunosuppressants apart from general management of infections.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Government of India, Ministry of Health and Family Welfare. Available from: https://www.mohfw.gov.in. [Last accessed on 2020 Aug 17].  Back to cited text no. 1
Prasad N, Bhadauria D, Sharma RK, Gupta A, Kaul A, Srivastava A. Dengue virus infection in renal allograft recipients: A case series during 2010 outbreak. Transpl Infect Dis 2012;14:163-8.  Back to cited text no. 2
Cao Y, Liu X, Xiong L, Cai K. Imaging and clinical features of patients with 2019 novel coronavirus SARS-CoV-2: Systematic review and meta-analysis. J Med Virol 2020;92:1449-59. doi: 10.1002/jmv.25822.  Back to cited text no. 3
Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A, et al. A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia. Kidney Int 2020;97:1083-8.  Back to cited text no. 4
Azevedo LS, Carvalho DBM, Matuck T, Alvarenga MF, Morgado L, Magalhães I, et al. Dengue in renaltransplant patients: A retrospective analysis. Transplantation 2007;84:792-4.  Back to cited text no. 5
Teixeira Mda G, Barreto ML, Costa Mda C, Ferreira LD, Vasconcelos PF, Cairncross S. Dynamics of dengue virus circulation: A silent epidemic in a complex urban area. Trop Med Int Health 2002;7:757-62.  Back to cited text no. 6
Alkin E, Azzi Y, Bartsh R. COVID-19 and kidney transplantation N Engl J Med 2020;328:2475-7.  Back to cited text no. 7
Aziz F, Muth B, Parajuli S, Garg N, Mohamed M, Mandelbrot D, et al. Unusually high rates of acute rejection during the COVID-19 pandemic: Cause for concern? Kidney Int 2020;98:513-4.  Back to cited text no. 8
Science. WHO launches global mega trial of the four most promising coronavirus treatments. Available from: https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments. [Last accessed on 2020 Jul 31].  Back to cited text no. 9
RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, et al. Dexamethasone in hospitalized patients with COVID-19-preliminary report. N Engl J Med 2020. (published online July 17,2020). https://doi.org/10.1056/NEJMoa2021436.  Back to cited text no. 10


  [Table 1]

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1 Immunosuppressants
Reactions Weekly. 2021; 1846(1): 171
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