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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 127-129

COVID-associated pulmonary aspergillosis in a post renal transplant patient


1 Department of Nephrology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Medicine, NKPSIMS, Nagpur, Maharashtra, India

Date of Submission02-Jul-2021
Date of Acceptance29-Jul-2021
Date of Web Publication31-Mar-2022

Correspondence Address:
Dr. Manish R Balwani
Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi - 440 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_67_21

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  Abstract 


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) is usually mild in general population, while in renal transplant patients, it can turn fatal. Some patients suffer from post COVID-19 secondary bacterial and fungal infections due to virus-induced immunosuppression. We here report a case of immediate post renal transplant patient who contracted COVID-19 illness and later developed pneumonitis which on BAL was found to be due to Aspergillus fumigatus. Through this case report, the author aims to highlight the importance of keeping check on post COVID-19 secondary opportunistic infections in post renal transplant patients. Early diagnosis with high index of suspicion is essential to start timely and effective treatment.

Keywords: Aspergillosis, COVID-19, immunosuppression, renal transplantation


How to cite this article:
Balwani MR, Pasari AS, Bhawane A, Gurjar P, Tolani PR. COVID-associated pulmonary aspergillosis in a post renal transplant patient. Indian J Transplant 2022;16:127-9

How to cite this URL:
Balwani MR, Pasari AS, Bhawane A, Gurjar P, Tolani PR. COVID-associated pulmonary aspergillosis in a post renal transplant patient. Indian J Transplant [serial online] 2022 [cited 2022 Dec 8];16:127-9. Available from: https://www.ijtonline.in/text.asp?2022/16/1/127/342441




  Introduction Top


Most of the coronavirus disease 2019 (COVID-19) patients have no or very mild symptoms, but in elderly, hypertensive, and diabetic patients, SARS-CoV-2 can be severe leading to severe acute respiratory syndrome (SARS).[1] Few (7.2%) of COVID-19-infected patients are sometimes coinfected by other pathogens.[2],[3] Renal transplant patients in immediate post transplant period are on high doses of immunosuppression which itself is a high-risk state for secondary opportunistic infections. Here, we are describing an immediate post renal transplant patient who developed post COVID aspergillosis infection.


  Case Report Top


A 32-year-old male with end-stage kidney disease secondary to focal segmental glomerulosclerosis underwent kidney transplant from a brain-dead deceased donor on February 25, 2021. Pre transplant COVID-19 reverse transcription–polymerase chain reaction (RT-PCR) test of both the patient and the cadaveric donor was negative. Induction was performed with rabbit anti-human T-lymphocyte immunoglobulin, and maintenance immunosuppression consisted of prednisone, tacrolimus, and mycophenolate mofetil. Pre transplant medical history revealed he had developed erythropoietin beta-related pure cell aplasia for which he received multiple blood transfusions in the last 3 years (above 50 units of packed red blood cell transfusion). Due to repeated blood transfusion, he developed hemosiderosis, for which he was on deferoxamine treatment. He developed acute pancreatitis on day 4 post transplant which was managed with hydration, IV antibiotics, and other conservative management. Ultrasound revealed gallbladder stone. Acute pancreatitis resolved in a week. On day 13 post transplant, he developed fever, cough, and generalized weakness which gradually increased over the next 24 h. His COVID-19 antigen test and RT-PCR came negative. High-resolution computed tomography (HRCT) chest revealed around 60% lung involvement on day 15 post renal transplant, typical of COVID-19 pneumonitis (CORADS category 6). On day 18 post renal transplant, his oxygen saturation on room air was 92% and dropped to 78% on walking 2 min. He was managed with oxygen support, IV remdesivir, IV steroids (methylprednisolone 40 mg twice a day for 5 days), and IVIG (5 g once a day for 5 days). As mentioned, Prednisolone was continued afterward as 20 mg once a day. Mycophenolate mofetil was stopped on day 14 post transplant, and tacrolimus dose was reduced to 0.5 mg twice per day. Due to the above complications, the patient's hospitalization was prolonged and, gradually, he responded to the aforementioned treatment and, on day 32 post transplant, he started maintaining normal oxygen saturation on room air. He had persistent cough till day 33 post renal transplant for which repeat HRCT chest was performed on April 2, 2021, which showed nodular cavitary lesions in both lungs [Figure 1]. Bronchoscopy was performed on April 3, 2021, which showed mobile normal vocal cords; the trachea was normal with reddish inflamed bilateral bronchus. Bronchoalveolar lavage (BAL) was done, and samples were sent for microbiological examination and Xpert MTB/Rif. BAL showed a high level of Aspergillus galactomannan antigen by ELISA method. Xpert MTB/Rif was negative for tuberculosis, and TB culture was also negative. The patient was started on oral voriconazole therapy. The patient improved clinically and cough decreased dramatically after 6 weeks of the aforementioned therapy. Antifungal treatment was planned to continue for total duration of 12 weeks. As mentioned, dose of prednisolone was reduced to 10 mg once a day. On day 45 post renal transplant, cyclophosphamide was started at a dose of 25 mg twice per day and increased to 50 mg twice per day on day 60 post transplant. Tacrolimus dose was increased to total of 1.5 mg per day on day 60 post transplant, and tacrolimus trough level was 6.2 ng/dl. At the 3 months, post renal transplant, he is maintaining normal renal functions with no proteinuria. His Hb has improved to 14 g/dl, and repeat HRCT chest at 3 months showed resolving chest lesions with few cavitary lesions in both upper lobes.
Figure 1: High-resolution computed tomography chest showing nodular cavitary lesions in both lungs

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  Discussion Top


COVID-19 is linked with a variety of complications, among which few can develop fungal or bacterial coinfections.[4],[5] In studies by Lansbury et al. and Intra et al., it was found in COVID-19 patients that those who were admitted to the intensive care unit (ICU) had a higher probability (57% of ICU cases) of acquiring a fungal or bacterial secondary infection.[5],[6] Our patient was also hospitalized in ICU at the time of COVID-19 infection, had nearly 60% lung involvement, and needed oxygen support. Few studies have reported an occurrence of aspergillosis in around 20%–30% of the severely ill COVID-19 patients, which is now referred to as COVID-19-associated pulmonary aspergillosis (CAPA).[7] These studies showed that fungal infections occurred mostly 14 days after the appearance of COVID-19 symptoms.[8] Our patient was detected with aspergillosis after 20 days of COVID-19 infection. Diagnosis of CAPA is challenging, as serum Aspergillus galactomannan enzyme immunoassay (GM EIA) is usually negative, which limits the reliability of serum-based diagnosis of CAPA.[8] In our case, we did not perform serum GM EIA. Serum GM EIA results are negative when the disease is limited to lung airways. When the disease is invasive, then serum Aspergillus GM EIA results can come positive.[9],[10] Lung aspergillosis can present in initial stage as only airway inflammation to advanced stage of airway necrosis and cavitary lesions which are revealed by imaging.[8] In our case report, HRCT chest showed nodular cavitary lesions in both lungs. Bronchoscopy was diagnostic in our case where BAL showed a high level of Aspergillus galactomannan antigen by ELISA method. Our patient had risk factors like end-stage renal disease, recent COVID-19 infection, and recent use of steroid for COVID-19 pneumonitis. In one study by Bartoletti et al., COVID-19 patients who received anti-interleukin-6 treatment and corticosteroids were reported to be at high risk for CAPA.[11] In another literature, CAPA was reported even without any prior corticosteroid treatment.[12]

The author is of the opinion that COVID-19 infection leads to immunosuppression, especially of T-cell-mediated immunity, which renders individuals susceptible to opportunistic infections like aspergillosis. Further detailed studies are needed to understand the immunosuppressive effect of COVID-19 virus in susceptible population.


  Conclusion Top


COVID-19 pandemic may lead to increase in opportunistic infections like aspergillosis due to viral-related immunosuppression, especially in already immunocompromised renal transplant recipients. One should be vigilant in post renal transplant settings to detect these post COVID infections early in the course of illness for early treatment and better prognosis.

Consent

Consent has been taken from the patient and the family of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and the family have given their consent for images and other clinical information to be reported in the journal. The patient and the family understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abdullah HM, Hama-Ali HH, Ahmed SN, Ali KM, Karadakhy KA, Mahmood SO, et al. A severe refractory COVID-19 patient responding to convalescent plasma; A case series. Ann Med Surg (Lond) 2020;56:125-7.  Back to cited text no. 1
    
2.
Chen X, Liao B, Cheng L, Peng X, Xu X, Li Y, et al. The microbial coinfection in COVID-19. Appl Microbiol Biotechnol 2020;104:7777-85.  Back to cited text no. 2
    
3.
Garcia-Vidal C, Sanjuan G, Moreno-García E, Puerta-Alcalde P, Garcia-Pouton N, Chumbita M, et al. Incidence of co-infections and superinfections in hospitalized patients with COVID-19: A retrospective cohort study. Clin Microbiol Infect 2021;27:83-8.  Back to cited text no. 3
    
4.
Zheng KI, Feng G, Liu WY, Targher G, Byrne CD, Zheng MH. Extrapulmonary complications of COVID-19: A multisystem disease? J Med Virol 2021;93:323-35.  Back to cited text no. 4
    
5.
Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with COVID-19: A systematic review and meta-analysis. J Infect 2020;81:266-75.  Back to cited text no. 5
    
6.
Intra J, Sarto C, Beck E, Tiberti N, Leoni V, Brambilla P. Bacterial and fungal colonization of the respiratory tract in COVID-19 patients should not be neglected. Am J Infect Control 2020;48:1130-1.  Back to cited text no. 6
    
7.
Fekkar A, Lampros A, Mayaux J, Poignon C, Demeret S, Constantin JM, et al. Occurrence of invasive pulmonary fungal infections in severe COVID-19 patients admitted to the ICU. Am J Respir Crit Care Med 2020;203:307-17.  Back to cited text no. 7
    
8.
Marr KA, Platt A, Tornheim JA, Zhang SX, Datta K, Cardozo C, et al. Aspergillosis complicating severe coronavirus disease. Emerg Infect Dis 2021;27:10.3201/eid2701.202896.  Back to cited text no. 8
    
9.
van de Groep K, Verboom DM, van de Veerdonk FL, Haas PA, van der Poll T, Schultz MJ, et al. Detection of invasive aspergillosis in critically ill patients with influenza: The role of plasma galactomannan. Am J Respir Crit Care Med 2019;200:636-8.  Back to cited text no. 9
    
10.
Bassetti M, Giacobbe DR, Grecchi C, Rebuffi C, Zuccaro V, Scudeller L, et al. Performance of existing definitions and tests for the diagnosis of invasive aspergillosis in critically ill, adult patients: A systematic review with qualitative evidence synthesis. J Infect 2020;81:131-46.  Back to cited text no. 10
    
11.
Rutsaert L, Steinfort N, Van Hunsel T, Bomans P, Naesens R, Mertes H, et al. COVID-19-associated invasive pulmonary aspergillosis. Ann Intensive Care 2020;10:71.  Back to cited text no. 11
    
12.
Rutsaert L, Steinfort N, Van Hunsel T, Bomans P, Naesens R, Mertes H, et al. COVID-19-associated invasive pulmonary aspergillosis. Ann Intensive Care 2020;10:71.  Back to cited text no. 12
    


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