Although the WHO has declared the end of the pandemic emergency, COVID-19 still poses a threat to immunocompromised patients. The COVID-19 pandemic has spread throughout the world over the last two years, causing a significant number of deaths. After three years, SARS-CoV-2 has lost its initial lethality but has shown a significantly worse prognosis for immunocompromised patients, especially those who have undergone lung transplantation, compared with the general population. This paper presents two compelling case studies that highlight the complex challenges of COVID-19 infection in lung transplant recipients. The first case involves a patient who received a bilateral lung transplant for pulmonary artery hypertension in 2009, followed by a kidney transplant in 2022. Surprisingly, despite an initially favorable clinical course after contracting COVID-19, the patient deteriorated rapidly and died within a few days due to extensive lung involvement. This case highlights the unpredictable nature of COVID-19 and its potentially devastating impact on lung transplant recipients. The second case involves a patient who underwent bilateral lung transplantation five years earlier for chronic obstructive pulmonary disease (COPD). This individual also contracted COVID-19 and had pre-existing complications, including chronic lung allograft rejection (CLAD) and diffuse bronchial stenosis. Following viral infection, the patient’s clinical condition deteriorated rapidly, with worsening bronchial stenosis. This case highlights the ability of COVID-19 to exacerbate pre-existing pulmonary complications in transplant recipients. These cases highlight the urgent need for increased vigilance and tailored management strategies when dealing with COVID-19 in lung transplant recipients. The unpredictable and detrimental course of the disease observed in these patients highlights the importance of implementing stringent preventive measures, such as vaccination and strict adherence to infection control protocols, in this vulnerable population. Further research is essential to gain a full understanding of the unique dynamics of COVID-19 in lung transplant recipients and to develop targeted interventions to improve their outcomes.

Background Surgery for thymic cancers is considered the key of curative treatment. Preoperative patients’ characteristics and intraoperative features might influence postoperative outcome. We aim to verify short-term outcomes and possible risk factors for complications after thymectomy. Methods We retrospectively investigated patients undergoing surgery for thymoma or thymic carcinoma in the period between January 1, 2008, and December 31, 2021, in our department. Preoperative features, surgical technique (open, bilateral VATS, RATS), intraoperative characteristics and incidence of postoperative complications (PC) were analyzed. Results We included in the study 138 patients. Open surgery was performed in 76 patients (55.1%), in 36 VATS (26.1%) and in 26 RATS (36.1%). Resection of one or more adjacent organs due to neoplastic infiltration was required in 25 patients. PC appeared in 25 patients (52% Clavien–Dindo grade I, 12% grade IVa). Open surgery had a higher incidence of PC (p < 0.001), longer postoperative in-hospital stay (p = 0.045) and larger neoplasm (p = 0.006). PC were significant related to pulmonary resection (p = 0.006), phrenic nerve resection (p = 0.029), resection of more than one organ (p = 0.009) and open surgery (p = 0.001), but only extended surgery of more organs was confirmed as independent prognostic factor for PC (p = 0.0013). Patients with preoperative myasthenia symptoms have a trend toward stage IVa complications (p = 0.065). No differences were observed between outcomes of VATS and RATS. Conclusions Extended resections are related to a higher incidence of PC, while VATS and RATS guarantee a lower incidence of PC and shorter postoperative stay even in patients that require extended resections. Symptomatic myasthenia patients might have a higher risk toward more severe complications.

INTRODUCTION:In this case report, we present a lung transplant recipient in immunosuppressive treatment infected by SARS-CoV-2 who developed abdominal distention of unknown origin. CASE PRESENTATION:In June 2020, a 40-year-old woman underwent a double lung transplant for hereditary pulmonary arterial hypertension (BMPR2 mutation). In November 2020, she was positive for SARS-CoV-2 and developed mild bilateral pneumonia without the necessity of hospitalization. The immunosuppressive maintenance regimen (tacrolimus, prednisolone, and mycophenolate mofetil) was adjusted, and an empiric antibiotic therapy was started. In March 2020, at the follow-up visit, the patient was afebrile but complaining about her abdominal distension. The abdomen was slightly bloated, painful on deep palpation. CT scan of the thorax showed a clear amelioration of the parenchymal findings, whilst the abdominal radiological study detects a widespread submucosal air collection in the transverse and right colon confirmed by a subsequent colonoscopy. Laboratory tests depicted no signs of infection with normal WBC count and serum lactate. For the mild symptoms, the patient was hospitalized with a conservative treatment consisting of bowel rest, parenteral nutrition, adequate hydration, and intravenous antibiotic therapy with ciprofloxacin and metronidazole. In the absence of any signs of complication, the patient was discharged two weeks later with a slight amelioration of the abdominal distension.DISCUSSION: Pneumatosis intestinalis (PI) is a rare condition characterized by the presence of gas within the wall of the large or small bowel. Many aspects of this condition are poorly understood, including etiology, pathogenesis, and clinical implication. It is usually asymptomatic, but a broad clinical spectrum is described in the Literature. Unfortunately, there are no algorithms concerning etiologic diagnosis or treatment. In our patient, PI resulted from lung transplant recipient on immunosuppressive therapy. According to the PI mechanical theory, the persistent cough due to viral pneumonia may have increased intra-abdominal pressure, facilitating the air collection within the bowel wall. Finally, SARS-CoV-2 infection may have been the ultimate trigger. It has been proven that ACE2 is highly expressed in enterocytes and that SARS-CoV-2 uses this as a receptor for its entry process, potentially causing damage to the bowel wall integrity. Additionally, glucocorticoids could prolong SARS-CoV-2 presence in the GI tract, and its potential risk of PI, and viral RNA has been detected for a longer time in the stool of patients on glucocorticoid therapy.CONCLUSIONS: PI is previously described in association with lung transplantation as a rare complication. However, a certain etiology is difficult to highlight although, in our patient, SARS-CoV-2 infection has been an additional risk factor.

A 49-year-old caucasian man was admitted to the Emergency Department for shortness of breath and cough. CT imaging showed bilateral a mild COVID-19 related pneumonia treated with O2 therapy and oral corticosteroids. Three weeks after discharge an HRCT find a giant bulla of the inferior lobe. The bulla was resected by VATS and the patient recovered completely. The development of the giant bulla in short time (less than two months) might be the result of SARS-CoV-2 infection. SARS-CoV-2 related pneumonia and corticosteroid therapy could be responsible for lung remodeling due to diffuse alveolar damage and later interstitial myofibroblastic proliferation.COVID-19 leads to pulmonary damages, which are still partially unknown and might result in development of bullae. In fit patient surgical treatment can be carried out safely.