The emergence of the novel coronavirus, SARS-CoV-2, and its associated clinical syndrome, COVID-19, resulted in the largest global pandemic since the 1918 influenza. While widespread in the general population, to date, there are few reports of COVID-19 in solid organ transplant (SOT) recipients. 1-5 Herein, we report a case of COVID-19 infection in the early postoperative period following lung transplantation (LT). A 68 year-old white female with idiopathic pulmonary fibrosis, gastroesophageal reflux disease, hyperlipidemia, and psoriasis was listed for bilateral LT with a lung allocation score of 31.8784. At admission for transplant, the patient reported feeling well without symptoms of acute respiratory infection. Vital signs included temperature, 37.1°C; heart rate, 78 beats per minute; blood pressure, 124/83 mm Hg; and oxygen saturation, 94% on 3 L/min oxygen. The donor, a 30 year-old female with a history of hypertension and inflammatory bowel disease treated with a tumor necrosis factor inhibitor presented to the hospital with severe headache, confusion, and vomiting. There was no history of fever or respiratory symptoms. She was intubated, and head CT revealed a large intracerebral hemorrhage. Due to poor neurologic prognosis, her family elected to pursue organ donation following cardiac death. Chest CT demonstrated "focal areas of consolidation in the bilateral dependent lower lobes with adjacent tree-in-bud opacities most consistent with pneumonia, possibly secondary to aspiration" (Figure 1A). Bronchoscopic examination identified erythematous mucosa of the trachea and main carina with purulent secretions in all lobes. Bronchoalveolar lavage (BAL) culture resulted in normal upper respiratory flora. No viral testing was performed, and no confirmed COVID-19 cases had been reported in the county of the donor hospital. p a O 2 on the last challenge arterial blood gas prior to procurement was 482 mm Hg.

Cytomegalovirus (CMV) prophylaxis with valganciclovir is the standard of practice in most transplant centers, but treatment-related leukopenia can limit valganciclovir’s use. Therefore, we evaluated letermovir, a novel antiviral agent recently approved for use in hematopoietic cell transplant patients as CMV prophylaxis, in lung transplant recipients unable to tolerate valganciclovir due to severe leukopenia. We performed a retrospective analysis of all lung transplant patients at our center who received letermovir for CMV prophylaxis between 1 December 2018 and 1 January 2020. A repeated measures mixed model was used to analyze white blood cell (WBC) trends, and descriptive statistics were used to analyze secondary endpoints, including CMV DNAemia, renal function, immunosuppression dosing, and allograft function. Seventeen patients were administered letermovir during the study period due to valganciclovir-induced leukopenia (median WBC nadir 1.1 K/uL, range <0.30–2.19 K/uL). Median WBC improvement was noted in 15 (88.2%) patients after starting letermovir. Breakthrough CMV DNAemia necessitating treatment occurred in two patients, with one of the two cases being due to patient noncompliance. CMV resistance to letermovir was detected in two patients, necessitating a change to an alternative agent in one of these patients. No major side effects were reported in any patient. Letermovir is a generally safe and effective alternative for CMV prophylaxis in lung transplant recipients unable to tolerate valganciclovir due to leukopenia.

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Examining conventional treatment protocols can lead to the development of novel immunosuppression concepts that will ultimately assist in favorably tilting the risk-benefit scale for these life-changing transplants.