Prolonged SARS-CoV-2 shedding and mild course of COVID-19 in a patient after recent heart transplantation

Abstract

In the coronavirus disease 2019 (COVID‐19) pandemic, organ transplant recipients are considered to be at high risk for an unfavorable outcome. However, in particular the role of immunosuppression in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) remains undetermined. Here, we present a 62‐year‐old male COVID‐19 patient with recent heart transplantation who developed only mild symptoms, but had prolonged virus shedding, and summarize the available data on COVID‐19 in cardiac allograft recipients. Initially the patient presented with a transient episode of fever and sore throat but no other symptoms, in particular no cough or dyspnea at rest. After diagnosis, immunosuppression was continued unchanged. On day 7, his temperature increased again with concurrent mild rise of C‐reactive protein, IL‐6, and pro‐B‐type natriuretic peptide levels. Hydroxychloroquine was started and continued for 7 days. While the patient no longer had clinical symptoms 20 days after initial presentation, virus culture of throat swabs on days 18 and 21 confirmed active virus replication and SARS‐CoV‐2 PCR remained positive on day 35 with copy numbers similar to the onset of infection. In conclusion, the immunosuppression regimen in transplant recipients with mild COVID‐19‐associated symptoms may be continued unchanged. However, it may contribute to delayed virus polymerase chain reaction conversion and thus possible prolonged infectivity.

A Review of Viral Shedding in Resolved and Convalescent COVID-19 Patients

“…Patients with albumin ≥ 35 g/L had a shorter duration of viral RNA shedding compared with those with albumin < 35 g/L, and the median times were 18 days and 20 days, respectively. Campioli et al and Decker et al suggested that the immunosuppressive therapy may contribute to delayed clearance of virus [11,14]. In addition, Campioli et al suggested that asthma may be a cause of delayed recovery.…”

“…In our review, immunosuppressive therapy was identified as a possible contributing factor for delayed clearance of the virus [11,14]. Similarly, Zhu et al reported prolonged detection of viral RNA in immunosuppressed renal transplant patients [34].…”

“…The detection of SARS-CoV-2 RNA in tears and conjunctival swabs highlights the role of the eye as a possible route of transmission of the disease *OR odds ratio, CI confidence interval, SARS-CoV-2 severe acute respiratory syndrome coronavirus 2, CHD coronary heart disease, RT-PCR reverse transcription polymerase chain reaction, RNA ribonucleic acid [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] facility or isolation [31,32]. Factoring insufficient testing capacity, economic strain, access to healthcare, and variable test results based on prolonged viral shedding, the WHO revised its criteria for discontinuing transmission-based precautions without requiring retesting [33].…”

SARS-CoV-2–specific T cells are rapidly expanded for therapeutic use and target conserved regions of the membrane protein

“…Though to date, relatively few immunocompromised patients have died of COVID-19 relative to the general population, prolonged illness and prolonged viral shedding has also been described, which could increase risk for other patients and staff. 37,38 Furthermore, even after recovery, this population is likely to be at risk for re-infection due to compromised adaptive responses. Adoptive T-cell immunotherapy may accordingly be beneficial for prevention or early treatment of COVID-19.…”

The duration of infectiousness of individuals infected with SARS-CoV-2

“…27 Both of the case reports which identified SARS-CoV-2 in culture beyond day 14 were of hospitalised patients with mild disease, 25 , 30 case reports described an immunocompromised patient who had recently had a heart transplantation. 25…”