Methylprednisolone/mycophenolate sodium/tacrolimus

Abstract

Methylprednisolone/mycophenolate sodium/tacrolimus COVID-19 and its worsening: case reportA 70-year-old woman developed COVID-19 and its further worsening during immunosuppression therapy with methylprednisolone, mycophenolate sodium and tacrolimus.The woman, who had undergone kidney transplantation in 2017, admitted to the emergency ward with shortness of breath for 1 week. She reported productive cough, fever and frequent watery diarrhoea. She had nausea and decreased appetite. She had been receiving immunosuppression therapy for her transplantation with tacrolimus 1mg twice daily, mycophenolate sodium [mycophenolic sodium] 180mg twice daily and methylprednisolone 4mg once daily [routes not stated]. At the emergency room, she exhibited a positive COVID-19 result from a nasal swab utilising RT-PCR (reverse transcription polymerase chain reaction). At the time of the initial evaluation, her physical examination revealed a blood pressure of 147/78mm Hg, heart rate (HR) of 98 beats/min with a regular rhythm, a strong pulse, and normal amplitude; a respiratory rate (RR) of 22 breaths/min, an axillary temperature of 36.9°C and an oxygen saturation of 95% ambient air. Laboratory tests showed normal leucocyte of 4540 /µL, increased level of CRP 55.3 mg/L, ferritin 378.3 ng/mL, normal D-dimer level and normal kidney function test. There was moderate hyponatraemia and tacrolimus level was found to be 4.3 ng/mL. Chest radiography revealed pulmonary consolidation in the right perihillar and left paracardial field. It was concluded that, COVID-19 was related to immunosuppression therapy with methylprednisolone, mycophenolate sodium and tacrolimus [duration of treatments to reaction onset not stated].The woman was therefore treated with an off-label lopinavir/ritonavir at a fixed dose combination for 14 days, an off-label hydroxychloroquine for 5 days and an off-label dexamethasone 6mg for 10 days. Hyponatraemia was treated with unspecified treatment. Her shortness of breath worsened on the third day of the hospitalisation, with an elevated respiratory rate 28 breaths/min and a drop in peripheral capillary oxygen saturation to 92%. Laboratory results showed increased levels of CRP 88.8 mg/L, ferritin 462.50 ng/mL and tacrolimus 24 ng/mL. Also, arterial PO2 level dropped to 58mm Hg. Worsening of her overall condition was noted and it was determined to be related to the immunosuppression therapy. Therefore, on the third day the hospitalization, treatment with tacrolimus, methylprednisolone and mycophenolate sodium was discontinued, and she was intubated. She was initiated on an off-label IV heparin therapy 1500IU in 1h followed by 350 IU/h. On the eighth day of the hospitalisation, improvement in chest radiography and laboratory results was noted, and arterial pO2 level increased to 73mm Hg. Her sputum culture was found to be positive for Stenotrophomonas maltophilia on the thirteenth day of the hospitalisation. Hence, moxifloxacin was initiated. On the sixteenth day of the hospitalisation, she was extubated and oropharyngeal/...