During SARS–CoV2 pandemic, transplant programs had to devise strategies to deal with the possibility of COVID–19–positive donors and recipients. In March 2022, a 60–year–old man with dilated cardiomyopathy on the transplant waitlist was admitted to our Unit as a possible donation was presented. On arrival, he tested positive for SARS–CoV2. The patient had no clinical evidence of COVID–19; he had completed the vaccination cycle; chest X–rays did not show interstitial pneumonia. Aware of the increased risk, we proceeded with the transplant. Sotrovimab, a novel anti–viral agent specific for COVID–19, was administered. Prophylactic antibiotics were started. He received anti–thymocyte immunoglobulins 125 mg for 2 days and methylprednisolone 1 g after aortic declamping and then 125 mg TID for 2 days for induction immunosuppression. Maintaining therapy included corticosteroids and tacrolimus. On the 7th day the patient tested negative at SARS–CoV2 swab. As kidney function worsened, hemodialysis was started. On the 17th day signs of cellulitis of the left thigh appeared, and inflammation indices (CRP, PCT) rose. A hemoculture positive for A. baumannii (MDR–AB) was obtained; hence the patient was treated with Cefiderocol and Colistine. A Cytosorb filter was added to the hemodialysis and Pentaglobin was started. After 3 weeks, hemodynamics started to improve, inotrope support was suspended, with reduction of inflammation indices, negative hemocultures, recovering kidney function. After two weeks, the patient abruptly presented fever, marked hypotension and dyspnea. He underwent intubation, inotrope therapy, broad–spectrum antibiotic therapy, intravenous Immunoglobulins and a cycle of Polymyxin B Hemoperfusion. Nevertheless, hemodynamics decidedly failed. Chest X–rays showed bilateral pneumonia. Hemocultures were positive for MDR–AB. Leukopenia developed (WBC 0,10). Three days after the first signs of a new infective episode, the patient had died. Notwithstanding the difficulties of SARS–CoV2 pandemic, tempestive diagnosis and treatment allow transplant programs to proceed unhindered.

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A 44–year–old man in apparent good health thus far presented with weight loss and fever preceded by shivers, profuse sweating, and arthralgias. Blood tests documented normal white blood count with slightly altered CRP and ESR. Chest X–rays did not find pleuro– parenchymal lesions with normal cardiac silhouette. Abdomen ultrasounds was regular. Due to the persistence of the symptoms, he was referred to a rheumatologist who diagnosed Adult Still’s disease (AOSD) and recommended therapy with prednisone and sulfasalazine, interleukin–1 inhibitor, with the resolution of the fever. After three months, because of the recrudescence of the fever, he was admitted to the emergency room a total–body CT–scan documented inflammatory–abscess lesions in the brain and hypodense areas in the spleen. ECG showed type 1 second–degree atrioventricular (AV) block. The patient was therefore transferred to the Cardiology Department; echocardiograms documented an endocardic mass on the aortic valve and suspected periannular abscess also infiltrating the interventricular septum. The patient underwent urgent surgery with excision of the aortic valve, opening and draining of the abscessual cavities, reconstruction of the aortic annulus with bovine pericardium patch and aortic valve replacement with bioprosthesis. The patient did not present further febrile episodes after surgery but a pacemaker implantation was necessary due to persistent AV block. Biological material sent for culture was positive for S. gallolyticus. AOSD is one of the most common conditions responsible for fevers of unknown origin. It is characterized by fever, arthritis, evanescent rash, leukocytosis, and multiorgan involvement. Yamaguchi criteria required for the diagnosis of AOSD are as follows: main criteria: Fever >39°C, lasting 1 week or more, Arthralgia or arthritis, lasting 2 weeks or more, Typical rash, Leukocytosis >10,000/mm3; Minor criteria: Sore throat, Recent development of significant lymphadenopathy, Hepatomegaly or splenomegaly, Negative tests for antinuclear antibodies and rheumatoid factor; Exclusion criteria: Infections, Malignancies, Other rheumatic diseases.

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