ABSTRACT
Introduction Heart tansplant (HT) recipients constitute a population at risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Efficay and safety of SARS-CoV-2 vaccine in this population is still yet to be established. It has been described, immune thrombotic thrombocytopenia, myocarditis and Guillain-Barre syndrome in individuals who received the ChAdOx1 SARS-CoV-2 vaccine. There are very few cases of acute rejection after SARS-CoV-2 vaccination post HT patients. We will describe a several outcome of heart function vaccine-induced. Case Report A 46-year-old heart transplanted male since 2015, started with persistent cough 15 days after a dose of adenoviral vector-based vaccine against SARS-CoV-2. As he had increased troponin and new left ventricular dysfunction, he underwent an endomyocardial biopsy, collected an panel reactive antibodies (PRA) and started pulse dose metylprednisolone. He developed an ischemic electrocardiographic alteration with a ST elevation and the coronary angiography found a thrombosis in the anterior descending coronary artery with no success with percutaneous treatment. Endomyocardial biopsy found no acute rejection, and PRA showed de novo donor specific antibodies (DSA). Despite treatment for antibodie-mediated rejection with plasmapheresis, human immunoglobulin and rituximab, he had a cardiogenic shock, refractory to inotropic support and intra-aortic balloon pump, requiring peripheral VA ECMO. Regardless of initial hemodynamic response and partial recovery of biventricular function, patient could not stand weaning from ECMO and inotropes. After rejection therapy, PRA showed no antibodies and patient was included in HT list and had a retransplant after 16 days without complications. Summary To the best of our knowledge, this is the firts report of antibodie-mediated rejection in heart-transplant patient with thrombotic complication after ChAdOx1 SARS-CoV-2 vaccine. Although vaccination remains the main approach of preventing SARS-CoV-2 infeccion, transplant recipients were not included in clinical trials, so its safety remains unknown in this population. More studies are needed in order to increase knowledge about vaccine outcomes in these individuals.
ABSTRACT
Purpose Heart transplant(HT) recipients with SARS-CoV-2 infection may be at high risk of developing critical illness. The aim was to describe the characteristics and clinical outcomes of HT recipients with coronavirus-19 disease(COVID-19). Methods We prospectively included all adult HT recipients who received the diagnosis of COVID-19 in our institution. Inclusion criteria were one or more clinical symptoms of SARS-CoV-2 infection in the previous seven days and positive SARS-CoV-2 RT-PCR in nasopharyngeal samples. The enrollment was carried out from April to June, 2020. Demographic features, clinical characteristics, modes of transmission, laboratory data and other known prognosis markers at admission and through follow up were recorded. Patients were categorized according to the ordinal scale developed by WHO Committee. Outcomes and follow up were recorded until Aug/2020. Results Twenty-one HT recipients were included, most of them were men (57%);with median age of 48 years old and median HT time of 12 mo. The majority needed hospitalization. Immunosuppressive therapy was reduced or withdrawn in the majority of patients, except from steroids. Ten patients were classified as having severe disease according to WHO Committee scale. Lymphopenia was an independent predictor of severe disease and absolute lymphocyte count <416/mm3 had 82% of sensitivity and 90% of specificity to define severe disease. Thirty-day mortality was 14%, similar to previously reported in other solid-organ transplant (SOT) cohorts. However, a longer follow up revealed increased 60-day mortality (33%) due to nosocomial infection. Conclusion In this case series of HT recipients with COVID-19, the 30-day mortality rate was similar to that previously reported in SOT recipient's cohorts, but a longer follow up revealed increased later mortality related to long in-hospital stay. Further, lymphopenia was associated with severe disease and worse prognosis. These findings suggest the need for strict long-term follow up of these patients.
ABSTRACT
Introduction The disease caused by the coronavirus 2019 (COVID-19) is mainly characterized by symptoms related to the upper respiratory tract associated with fever and constitutional symptoms, progressing in the most severe cases to pneumonia and severe acute respiratory syndrome (SARS). However, due to the increasing number of cases, atypical presentations have been found. Among them, thromboembolic manifestations stand out, since the virus itself seems to predispose to changes in the coagulation system. Case Report A 62-year-old male patient who underwent cardiac transplantation 6 months ago, secondary to chagasic cardiomyopathy, had pain and edema in his left foot for 1 week. Upon admission, he was eupneic, afebrile, heart rate of 96bpm, blood pressure of 120 × 70mmhg, with edema and erythema on his left foot. Chagas reactivation, cellulite or deep vein thrombosis were the diagnostic hypotheses suggested. Soft tissue ultrasound and venous doppler of the left lower limb were compatible with deep venous thrombosis and superficial thrombophlebitis. Skin lesion biopsy confirmed Chagas reactivation. Antibiotic therapy with cefazolin, full anticoagulation with enoxaparin and treatment with benzonidazole were introduced. In the second day of hospitalization, patient presented myalgia and dry cough, in addition to an increased C-reactive protein and multiple ground-glass opacities on computed tomography of the chest, suggestive of COVID-19. This finding was corroborated by a positive result of RT-PCR for SARS-COV2. The patient evolved with SARS, requiring progressive use of vasoactive drugs, mechanical ventilation and pronation. Summary It is currently known that COVID-19 increases the risk of thromboembolic events, especially in hospitalized patients, reaching an incidence of 25%, even in the presence of effective prophylaxis. Several mechanisms have been proposed for this association, but not with robust evidence. Despite these increased cases, there are no reports in the literature of initial presentation with a thromboembolic event in a heart transplant patient, emphasizing the importance of clinical suspicion and appropriate investigation.
ABSTRACT
Introduction The relation between coronavirus 2019 disease (COVID-19) and thrombotic events is well established, and both arterial and venous thrombotic events are described. Although arterial events occur in about 3.6 to 10.5% of critically ill patients, they are usually stroke or acute myocardial infarction. Arterial thrombosis of other sites is rare. Case Report We report a case of a 28-year-old male heart transplant recipient admitted into emergency department presenting right flank pain associated with fever, chills, nausea and vomiting for three days. Apart from diabetes mellitus and dyslipidemia, he had no other comorbidity and he was on regular immunosuppression. Physical exam revealed right costovertebral angle tenderness. Blood tests showed C-reactive protein of 317mg/dL, lactate dehydrogenase of 1827U/L, D-dimer of 4126ng/mL, ferritin of 651ng/mL and leukocytosis of 16100/mm³. An abdominal and thoracic computed tomography scan (CT scan) revealed sparse luminal peripheral thrombi in the descending thoracic aorta. One of the thrombi extended to right renal artery ostium and caused subocclusion of the proximal segment of this artery. Right kidney presented multiple renal infarcts. Also ground-glass opacities were found in 25% of pulmonary parenchyma. COVID-19 was suspected and nasopharynx real-time fluorescence polymerase chain reaction result for SARS-CoV-2 was positive. Coagulopathy tests were performed because of atypical presentation and lupus anticoagulant (LAC) was positive. Hydration, antibiotics and anticoagulation with enoxaparin were prescribed. The patient recovered and became asymptomatic. Warfarin was prescribed and patient was discharged after 15 days of hospitalization. Summary This case report illustrates the heterogeneity of clinical presentation of COVID-19 and reinforces the existence of a prothrombotic state, even in the outpatient setting. Moreover, it adds information to the recent reports regarding the presence of antiphospholipid antibodies in COVID-19, although their importance in the pathophysiology of thromboembolic events in this setting is still not clear. The implication of these findings in transplant recipients is even less established, and this case report highlights the need for further research.