Spontaneous Splenic Rupture in a Patient with Active Sars-Cov-2 Infection

INTRODUCTION: Atraumatic splenic rupture (ASR) is an extremely rare but life-threatening event. Reported incidence ranges from 0.5% - 3.2% and mortality ranges from 12.2% to 20%. The most common predisposing pathologies to ASR are neoplastic and infectious, with the most common infection being mononucleosis. SARS-CoV-2 presents with a wide range of symptoms including cough and anosmia. Herein, we report a case of a patient with ASR and an active SARSCoV- 2 infection without any other predisposing factors. Given the wide range of complications associated with this novel infection, we believe SARS-CoV-2 may be the primary etiological factor in this case. DESCRIPTION: A 21-year-old man presented to Ruby Memorial Hospital with a chief complaint of acute onset severe left upper quadrant abdominal pain with no history of trauma. He had signs of peritonitis. The patient admitted to having a cough the prior week. A RT-PCR SARS-CoV-2 test was positive and rapid mononucleosis test was negative. Ultrasound showed free intra-peritoneal fluid and an irregular spleen. CT angiogram showed a grade 3 splenic subcapsular hematoma. The patient underwent exploratory laparotomy, which revealed a hemoperitoneum with a ruptured spleen. A splenectomy was performed. Three days post-splenectomy, he developed leukocytosis. A chest x-ray showed bibasilar opacities which was confirmed to be SARS-CoV-2 pneumonia. CBC with differentials did not show any evidence of hematological pathology. Streptococcus and legionella urine antigens were negative. Examination of the spleen showed no pathology or signs of malignancy;however, there was focal capsular disruption and hemorrhage. He was discharged nine days post-operation. DISCUSSION: To this author's knowledge, three other cases of ASR linked to SARS-CoV-2 infection are reported in the literature thus far. The average age of these three patients was 59, which is significantly higher than the patient in our case. SARS-CoV-2 has been shown to greatly increase the risk of thrombotic events, including DVT and PE. Formation of microthrombi may lead to splenic congestion. Our patient, due to his young age, lack of co-morbidities, and minimal abnormal histopathological findings, shows a potential novel complication of SARS-CoV-2 infection as no other etiology has been identified.

Use of Kidneys from Hepatitis C Nat Positive Donors for Uninfected Recipients: Early Results from a Rural Appalachian Kidney Transplant Program

Purpose: Increasing mismatch between kidneys available for transplant and the number of patients on the transplant wait list has led to research into novel sources of organs. One such source is kidneys from hepatitis C NAT positive deceased donors. This was previously deemed unforbidden territory due to the risk of disease transmission;however, with the development of direct-acting antiviral agents for effective treatment of Hepatitis C, this organ pool is now usable. Method(s): A retrospective analysis of outcomes of Hepatitis C NAT positive kidney transplants into Hepatitis C seronegative recipients was conducted at newly opened Appalachian transplant center. Due to insurance constraints, the criteria to initiate hepatitis C therapy was seroconversion to positive Hepatitis C PCR. Outcomes examined include median creatinine, glomerular filtration rate (GFR), liver function tests, recipient Hepatitis C seroconversion, concomitant Ebstein Barr virus (EBV), Cytomegalovirus (CMV) or polyoma hominis (BK) activation, morbidities and mortality. Result(s): Six transplants (of 15 total kidney transplants) from Hepatitis C NAT positive donors were performed in the first year of establishment. Male to female ratio was 2:1 and median patient age was 55.7 years (Range 42-73 years). Median follow-up was 10 months (Range 2-12 months). Diabetes and hypertensive nephrosclerosis were the most common causes of end stage renal disease at 40%. The average time on dialysis was 2.9 years (Range 1-6 years), the most common type being hemodialysis (67%) followed by peritoneal dialysis (33%). Average time on transplant waitlist was 5.57 months (Range 1.2-13.2 months). All patients seroconverted but with treatment, by 24 weeks all patients maintained undetectable viral loads. Patient survival rate was 83% with a death censored graft survival rate of 100%. One patient died due to respiratory failure from COVID-19 infection. Median creatinine and GFr were 1.96 mg/dL (Range 1.8 - 2.6 mg/dL) and 41.3 (Range 35.3 - 50) respectively. One case each of acute antibody and T cell mediated rejection was seen (6.7%), which were treated successfully. CMV, BK and EBV virus reactivation were seen in one patient each (6.7%). The most common complication was COVID-19 infection (50%) followed by neutropenia (33%). Conclusion(s): With the development of direct-acting antiviral agents offering complete cure of Hepatitis C, kidneys from Hepatitis C positive donors can be used for transplantation with excellent outcomes.

Successful Implementation of a Rural Appalachian Kidney Transplant Program, One Year Outcomes

Purpose: Kidney transplantation has become the optimal treatment for end stage renal disease (ESRD), allowing dialysis free survival. Despite widespread availability of transplant programs;rural patients have limited access to transplantation due to several barriers including increased travel time and financial burden. We report outcomes after establishment of a kidney transplant program serving rural West Virginia. Method(s): A retrospective review of the first 15 kidney transplants performed at a newly established Appalachian transplant program was conducted. Primary outcomes measured were graft survival and function. Other outcomes included graft rejection, patient survival and complications. Data related to patient demographics, etiology of ESRD, type of renal replacement therapy, time on transplant waitlist and average travel to transplant center were also collected. Result(s): The first 15 kidneys transplanted had an overall death censored graft survival rate of 100%. Median patient age was 53 (Range 31- 73 years) and a median follow-up of 6 months (Range 1-13 months). The average time on dialysis for this cohort was 4 years (n=13, Range 1-6 years) and average time on waitlist was 4.06 months (Range 0.4-13.2 months). The most common type of dialysis was hemodialysis (77%) followed by peritoneal dialysis (15%). Two patients were predialysis. Diabetes with hypertension (20%), IgA nephropathy (13%) and diabetes without hypertension (13%) were the most common causes of ESRD. Median graft creatinine was 1.51 mg/dL (Range 1.26 - 1.83 mg/dL) with a glomerular filtration rate (GFR) at 51.38 (Range 41.86-70) at one year. One patient developed acute antibody mediated rejection and one developed borderline T cell mediated rejection (13.3%), which were successfully treated with steroids, plasmapheresis and immune globulin therapy. Two patients died (13.3 %);one from acute respiratory failure following coronavirus (COVID-19) infection and one from cardiac arrest secondary to myocarditis (possible COVID-19). Patients experienced COVID-19 infection at a rate of 13.3 %. The average distance patients had to travel was 94 miles (Range 12 - 164 miles) with a travel time of 1 hour and 52 minutes on average (Range 20 minutes - 2.5 hours) to reach the transplant center. Conclusion(s): We report comparable outcomes from our new rural transplant program despite several barriers to delivery of quality care to our population.