Indian Journal of Transplantation

CASE REPORT
Year
: 2022  |  Volume : 16  |  Issue : 2  |  Page : 234--236

Reinfection of SARS-CoV-2 in kidney transplant recipient


Amresh Krishna1, Abhishek Kumar2, Prit Pal Singh1, Prem Shankar Patel1,  
1 Department of Nephrology, IGIMS, Patna, Bihar, India
2 Department of Nephrology, Paras HMRI Hospital, Patna, Bihar, India

Correspondence Address:
Dr. Abhishek Kumar
Consultant Nephrologist, Paras HMRI Hospital, Raza Bazar, Bailey Road, Patna - 800 014, Bihar
India

Abstract

Coronavirus disease-2019 (COVID-19) which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported from Wuhan, China, and later became a pandemic. While infection is very common, reinfection with SARS-CoV-2 is rare because immune responses from past infection reduce the risk of reinfection. In this report, we describe the case of a kidney transplant recipient who was reinfected with SARS-CoV-2 after successfully recovering from moderate COVID-19, 6 months ago. The first infection occurred in September 2020 while the reinfection occurred in April 2021. Our case highlights that kidney transplant recipients can be reinfected with COVID-19, and therefore, recovery from a primary infection should not be taken as license to shun COVID-related precautions. The disease severity, clinical course, and outcome of reinfection may be different from the first infection.



How to cite this article:
Krishna A, Kumar A, Singh PP, Patel PS. Reinfection of SARS-CoV-2 in kidney transplant recipient.Indian J Transplant 2022;16:234-236


How to cite this URL:
Krishna A, Kumar A, Singh PP, Patel PS. Reinfection of SARS-CoV-2 in kidney transplant recipient. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3 ];16:234-236
Available from: https://www.ijtonline.in/text.asp?2022/16/2/234/349368


Full Text



 Introduction



Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel virus which causes coronavirus disease 2019 (COVID-19). It was first reported from Wuhan, China, on December 31, 2019. Later, it became a pandemic spreading globally by March 2020. Till mid-July 2021, approximately 188 million cases have been reported worldwide with about 4 million deaths.[1] While infection is very common, reinfection with SARS-CoV-2 is rare because immune responses from past infection reduce the risk of reinfection by 84% for at least 7 months.[2] However, this may not be completely true in special circumstances such as older individuals, people with comorbidities, and immunocompromised state. The possible reason may be that because of the immunocompromised status, the antibody response to infection or vaccination may not be as robust as immunocompetent individuals.

In this report, we describe the case of a kidney transplant recipient who was reinfected with SARS-CoV-2 after successfully recovering from moderate COVID-19, 6 months ago.

 Case Report



A 34–year-old male received a live-related, ABO-compatible renal allograft from his sister October 1, 2019. Antithymocyte globulin induction was used at time of transplant and then he was on triple drug immunosuppression including tacrolimus, mycophenolate mofetil (MMF), and prednisolone. He was discharged 10 days posttransplant after an uneventful hospital stay with a baseline serum creatinine of 1.0 mg/dl. In the postdischarge follow-up, he remained asymptomatic with stable graft function. In the 1st week of September 2020, he presented to the outpatient department (OPD) with the complaints of fever with cough, shortness of breath, and abdominal discomfort of 4 days duration. On evaluation, his reverse transcriptase–polymerase chain reaction (RTPCR) for SARS-CoV-2 came positive on September 12, 2020. His inflammatory markers were raised (C-reactive protein [CRP] = 90 mg/L, interleukin [IL-6] = 55 pg/mL, and d-Dimer = 2.4 μg/mL). As per the institutional protocol, the patient was referred to a dedicated COVID hospital, where he remained admitted for 23 days (September 17, 2020–October 10, 2020). During his hospital stay, his high-resolution computed tomography chest was done which showed the left lower lobe patchy consolidation with a computed tomography (CT) severity score of 4/25 [Figure 1]. The CT severity score is a 25-point scoring based on the visual assessment of ground-glass opacity of each lobe of lung. A score of 7 or less is considered “mild,” 8–17 is “moderate,” and 18 or more is “severe.” Based on overall clinical parameters and laboratory findings, he was labeled as a “moderate” category of COVID-19 and managed with supportive treatment including supplemental oxygen. His MMF was stopped while prednisolone and tacrolimus continued without any dose modification. The patient showed gradual improvement in his symptoms with the treatment. His serum creatinine went up to 2.4 mg/dL which came back to 1.10 mg/dl by the time of discharge. He became afebrile 11 days after admission. By October 6, he could maintain oxygen saturation of 95% on room air. His RTPCR for SARS-CoV-2 became negative on October 9, 2020, and he was discharged a day later. He continued follow-up with us on OPD basis. His MMF was restarted a month later in November 2020. He remained asymptomatic for the next 6 months. He was advised to undergo COVID-19 vaccination but he did not comply. In April 2021, he again became symptomatic with fever and cough. He was advised RTPCR testing for SARS-CoV-2 which came positive on April 30, 2021. In view of his mild symptoms, he was advised treatment at home. MMF was again stopped while prednisolone and tacrolimus were continued without dose modification. Other treatment for COVID-19 as per latest guidelines was also advised. He improved with this treatment and became asymptomatic in 5 days. On his own, he got repeat testing for SARS-CoV-2 on May 17, 2021, which was reported as negative. During this episode, his inflammatory response was clinically milder; however, we could not do inflammatory markers such as CRP, IL-6, d-Dimer, ferritin, or a CT scan of chest. The patient is still under regular OPD follow-up and last visited on July 17, 2021. This time we did his COVID-19 immunoglobulin G antibody titer which was 20 AU/mL (where <12 AU/mL is considered negative). His MMF has been restarted and he is asymptomatic with a serum creatinine of 1.18 mg/dl. The timeline of the events is shown in [Figure 2].{Figure 1}{Figure 2}

 Discussion



Viral infections usually induce an immune response which provides the protective antibodies against the virus which develop within 2–3 weeks of infection. SARS-CoV-2 is no exception to this. The most cases with SARS-CoV-2 infection develop protective antibodies against the virus which provide immunity against reinfection.[3] These antibodies have been detected for up to 6 months after infection.[4],[5] Reinfection with SARS-CoV-2 has been rare with reported incidence of 0.31% as per an Italian study by Vitale et al.[6] However, immunocompromised patients like kidney transplant recipients may not be able to mount robust immune response even after infection. In addition, antibodies against a virus do not necessarily mean “neutralizing” antibodies which provide protection from reinfection. Therefore, kidney transplant recipients remain vulnerable not only for COVID-19 infection but also reinfection.

Our case is unique because, while some cases of reinfection have been reported in general population, such reinfection in transplant recipients is very few. To the best of our knowledge and belief, no such case of reinfection in kidney transplant recipient has been reported from India until now. On extensive literature search online, we found a case report from Spain by Borja Quiroga et al. who reported reinfection in a kidney transplant recipient but the patient expired during the second infection episode.[7] In general population, reinfection has been reported relatively more frequently. Tillett et al. reported a case of reinfection from Washoe County in the US state of Nevada with different strains of SARS-CoV-2 in January 2021.[8] Another case report from Brazil by Torres et al. shows a more aggressive reinfection by a different strain in a female medical doctor.[9] In a systematic review of 17 cases of reinfection who had genetic analysis of virus done, authors concluded that reinfection with different strains is possible.[10]

Hence, the review of literature suggests that reinfection of COVID-19 is a rare event occurring in <1% of cases. When it comes to kidney transplant recipients, such reports are even rarer. Therefore, our case report adds to knowledge pool about a rare event in an important subset of population concerning physicians and nephrologists. We believe that if the pandemic continues at the current rate, more such cases of reinfection may be found which poses a diagnostic and therapeutic challenge.

 Conclusion



Our case highlights that kidney transplant recipients can be reinfected with COVID-19, and therefore, recovery from a primary infection should not be taken as license to shun COVID-related precautions. The disease severity, clinical course, and outcome of reinfection may be different from the first infection. Furthermore, as a physician, we should not rule out possibility of COVID-19 in patients with previous history of infection and presenting with typical symptoms of COVID. Finally, our case report also highlights the importance of vaccination in all especially the so-called at-risk category.

Declaration of patient consent

The authors certify that patient consent has been taken for participation in the study and for the publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Available from: https://covid19.who.int/. [Last accessed on 2021 Jul 15].
2Hall VJ, Foulkes S, Charlett A, Atti A, Monk EJ, Simmons R, et al. SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: A large, multicentre, prospective cohort study (SIREN). Lancet 2021;397:1459-69.
3Khoury DS, Cromer D, Reynaldi A, Schlub TE, Wheatley AK, Juno JA, et al. Neutralizing antibody levels are highly predictive of immune protection from symptomatic SARS-CoV-2 infection. Nat Med 2021;27:1205-11.
4Lau EH, Tsang OT, Hui DS, Kwan MY, Chan WH, Chiu SS, et al. Neutralizing antibody titres in SARS-CoV-2 infections. Nat Commun 2021;12:63.
5Edara VV, Hudson WH, Xie X, Ahmed R, Suthar MS. Neutralizing antibodies against SARS-CoV-2 variants after infection and vaccination. JAMA 2021;325:1896-8.
6Vitale J, Mumoli N, Clerici P, De Paschale M, Evangelista I, Cei M, et al. Assessment of SARS-CoV-2 reinfection 1 year after primary infection in a population in Lombardy, Italy. JAMA Intern Med 2021;181:1407-8.
7Quiroga B, Fernández Ramos A, Delgado Arroyo A. COVID-19 reinfection in a kidney transplant recipient, time for rethinking? Nefrologia (Engl Ed) 2021;S0211-6995(21)00088-6. [Epub ahead of print].
8Tillett RL, Sevinsky JR, Hartley PD, Kerwin H, Crawford N, Gorzalski A, et al. Genomic evidence for reinfection with SARS-CoV-2: A case study. Lancet Infect Dis 2021;21:52-8.
9Torres DA, Ribeiro LD, Riello AP, Horovitz DD, Pinto LF, Croda J. Reinfection of COVID-19 after 3 months with a distinct and more aggressive clinical presentation: Case report. J Med Virol 2021;93:1857-9.
10Wang J, Kaperak C, Sato T, Sakuraba A. COVID-19 reinfection: A rapid systematic review of case reports and case series. J Investig Med 2021;69:1253-5.