COVID-19 associated fungal co-infections in Solid Organ Transplant Recipients: A single center case series

Background. During the ongoing Coronavirus disease of 2019 (COVID-19) pandemic, there have been increasing reports of viral, bacterial and fungal co-infections. Two COVID-19-associated fungal infections (CFIs) have been identified - COVID-19 associated pulmonary aspergillosis (CAPA) andCOVID-19 associated mucormycosis (CAM), but incidence and occurrence in solid organ transplant recipients (SOTRs) is limited. We describe our experience with CFIs in SOTRs with COVID-19. Methods. In a single center retrospective study at a large volume transplant center in South Florida, USA, we included adult SOTRs (>=18 years) diagnosed with COVID-19 between March 1st 2020 and January 31st 2022, with subsequent diagnosis of CFI. We collected information related to demographics, comorbidities, COVID-19 diagnosis and therapeutics, and CFI diagnostics and management. Data obtained was analyzed descriptively. Results. We identified 612 SOTRs with COVID-19, of which 23 (3.8%) were diagnosed with CFIs. The patients were predominantly male (17/23, 73.9%), with median age of 59 years (range 43-79) [Table 1]. Twenty (86.9%) were kidney transplant recipients. Majority of SOTRs had lymphopenia (18/23, 78.3%) with elevated inflammatory markers at time of COVID-19 diagnosis. They received most commonly remdesivir and corticosteroids for COVID-19, with 22 (95.6%) needing intensive care unit admission and 19 (82.6%) needing continuous renal replacement therapy. CFIs were diagnosed at median 21 days (range, 3-161) after initial COVID-19 diagnosis. Probable CAPA was diagnosed in most patients (16/23, 69.6%), with CAM noted in 1 patient [Table 2]. 34.8% (8/23) had specific fungal species identified, with elevated fungal markers noted in 95.6% (22/23). Concurrent or prior cytomegalovirus DNAemia was noted in 26.1% (6/23). Patients were followed for median 70 days (range, 19-572), with median hospitalization duration 56 days (range, 7-204). Mortality was noted in 73.9% (17/23). Table 1: COVID-19 related clinical characteristics in study patients (N=23) Table 2: CFI-related clinical characteristics in study patients (N=23) Conclusion. Fungal co-infections were noted in a small proportion of our SOTRs, with poor outcomes. Transplant physicians should have a high suspicion for early diagnosis and treatment of CFI. Further studies are needed to determine predictors for CFI and role for anti-fungal prophylaxis.

Reply to: "Herpes zoster seven days after SARS-CoV-2 vaccination in a patient with ankylosing spondylitis under adalimumab" by Josef Finsterer.

Not available.

Erythema nodosum after COVID-19 vaccine.

The current coronavirus disease 2019 (COVID-19) pandemic is a global challenge with strong medical and socioeconomic implications. Hopes have been placed in the development of various vaccines. As the vaccination campaign is in progress, adverse effects need to be monitored closely. Possible side effects range from minor events to more serious manifestations. In this article, we describe two cases of erythema nodosum (EN) after COVID-19 vaccination in two previously healthy female patients of 59 and 51 years, respectively. Most of the usual etiologies of EN were excluded by laboratory testing. EN was successfully treated with corticosteroids. Remarkably, in the first case, a relapse occurred 48 hours after the second dose of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. In this case series, we describe two unusual occurrences of EN after vaccination with an mRNA COVID-19 vaccine and a viral vector vaccine, respectively, and we discuss the available related literature.

Herpes zoster infection following mRNA COVID-19 vaccine in a patient with ankylosing spondylitis.

Since the severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) pandemic outbreak, vaccines gained a growing role. Possible vaccine-related side effects range from minor local events to more prominent systemic manifestations up to anaphylactic reactions. A heterogeneous spectrum of cutaneous reactions has been reported, ranging from local injection site reactions to urticarial and morbilliform eruptions, pernio/chilblains and zoster flares. Here, we describe a case of varicella zoster virus reactivation following mRNA coronavirus 2019 vaccine and discuss the available literature upon the topic published so far.

Covid-19 in hiv-infected solid organ transplant recipients: A case series

Purpose: Coronavirus disease 2019 (COVID-19) is associated with increased mortality and morbidity in immunosuppressed patients. Data on management and outcomes in HIV-infected solid organ transplant (SOT) recipients is lacking. Methods: Single center, retrospective case series of HIV-infected SOT recipients who were diagnosed with COVID-19 by nasopharyngeal reverse transcriptasepolymerase chain reaction (RT-PCR) between April to November 2020. All patients had anti-retroviral therapy (ART) induced HIV viral load suppression at diagnosis. Results: Six consecutive patients were identified (Table.1). Four patients required hospitalization;2 were managed outpatient. Four were symptomatic with fever (75%), cough (50%), dyspnea (50%) and diarrhea (25%). An increase in inflammatory markers was seen in all patients, however only 4 (66%) required supplemental oxygen. Median time of follow up was 75 (range, 14-205) days. On diagnosis, first mycophenolate mofetil was discontinued or dose decreased by half. Calcineurin inhibitors and prednisone were continued. In addition, investigational therapies hydroxychloroquine, tocilizumab, remdesivir, dexamethasone were used in 3 (50%), 1 (17%), 1 (17%), 1 (17%), respectively (Table 2). All patients were on protease inhibitor sparing ART. A decrease in CD4 count from baseline was seen at the time of diagnosis which recovered over time. Overall, 5 (83%) survived, 1 (17%) died, 1 (17%) kidney transplant recipient had biopsy-proven acute T-cell mediated rejection 9 days after diagnosis with subsequent graft loss. Secondary infections were diagnosed with positive blood or respiratory cultures in 3 (50%). Death reported was due to septic shock from a secondary infection. Three patients had a negative SARS-CoV-2 RT-PCR at a median of 25 (range, 20-56) days from diagnosis. Conclusions: We report good outcomes in this unique, high risk cohort of HIVinfected SOT recipients. Balancing a decrease in immunosuppression and monitoring graft function to avoid graft loss is extremely important. Further studies are needed to determine the cumulative effect of HIV infection and organ transplant status on the severity of COVID-19.

Clinical outcomes of solid organ transplant recipients treated with REMDESIVIR and convalescent plasma for COVID-19 at the largest transplant center in The United States

Purpose: Solid organ transplant recipients (SOTr) are at high risk for severe disease with SARS-CoV-2. Data on efficacy of potential treatment options and long-term outcomes are lacking. We describe our experience with use of remdesivir and convalescent plasma in SOTr with COVID-19. Methods: Single-center, retrospective cohort study of SOTr diagnosed with SARSCoV- 2 infection by PCR from March 1st to September 30th, 2020. Multivariate logistic regression analysis was performed based on univariate analysis to identify the risk factors for higher mortality. Results: 129 SOTr were identified (Table. 1). Median time from transplant to diagnosis of infection was 27 (IQR, 8-73) months. 48 (37.2%) and 27 (21%) patients received remdesivir and convalescent plasma, respectively (Table 2). 5/48 (10.4%) patients developed mild transaminitis that did not warrant discontinuation of therapy. No adverse effects were seen with convalescent plasma. Anti-metabolite agents were decreased or stopped in majority of the patients (81%). During follow-up, 12 (9%) patients developed clinically suspected acute rejection. Death, graft loss, and secondary infection occurred in 15 (12%), 20 (16%), and 20 (16%) recipients, respectively. RT-PCR negativity was achieved at a median of 37 (IQR, 25-41) days. Risk factors identified for high mortality were elevated creatinine (p=0.029, Odds ratio[OR] 1.5, 95% Confidence Interval[CI] 1.0- 2.1) and older age (p=0.003, OR 1.1, 95% CI 1.0 - 1.2) at the time of diagnosis. Conclusions: SARS-CoV-2 RT-PCR positive SOT recipients in our cohort had favorable outcomes. Use of remdesivir and convalescent plasma was found to be safe. Older age and elevated creatinine at the time of diagnosis were found to be risk factors for higher mortality.