ABSTRACT
Purpose: SARS-CoV-2 can result in a range of infections from asymptomatic disease to progressive COVID-19 and death. In some patients with COVID-19 Lung Disease (C19LD), lung transplantation (LTx) may be lifesaving. Up to 10% of LTx in the US is currently for patients with C19LD. Understanding the characteristics and outcomes of these patients is critical. Method(s): A open-access electronic registry was established to collect de-identified data from pts who have undergone LTx for C19LD from centers globally. The study was IRB approved at Northwestern with a wavier for consent (no PHI is collected sites could submit data about pre-Tx, peri-Tx and post-Tx course). Follow-up for 1-yr post-LTx was collected. Result(s): To date, 23 patients with complete day 30 post-LTx data have been entered into the registry. Patient demographics and pre-Tx status are shown in Table 1. 3 patients required oxygen prior to COVID-19 infection. All sites required neg PCR tests prior to listing (22 (95.7%) require 2 neg PCRs). LTx occurred 150 days post-infection and none developed COVID-19 in the first 30 days. Post-Tx ICU LOS averaged 18.6 days with total post-tx hospitalization of 36.3 days (See Table 2). Most LTx experienced infectious and non-infectious morbidity. Most (47.8%) required an additional 36.8 days of rehab. 1 patient died within 30 days due to sepsis. Conclusion(s): The contribution of cases to this international registry is ongoing. While outcomes of LTx for C19LD are generally good, patients experience prolonged post-transplant hospitalization, rehabilitation and significant morbidity.
ABSTRACT
Introduction: Encephalopathy in a transplant recipient is a challenging clinical presentation that requires a broad differential (both infectious and noninfectious) and consideration of exposures. West Nile Virus (WNV) encephalitis is a rare etiology of encephalopathy in a transplant recipient with controversial management. Case: A man in his seventies presented due to encephalopathy in September 2021. Medical history was significant for deceased donor kidney transplant in September 2020 and myasthenia gravis. Immunosuppression consisted of tacrolimus, mycophenolic acid, and prednisone 10 mg daily. He was on fluconazole for coccidioidomycosis prophylaxis. Symptoms consisted of worsening weakness over five days and headaches for two days. On admission, he was febrile to 38.1° C and had altered mental status. He was started on empiric meningitis treatment with ampicillin, vancomycin, cefepime, and acyclovir, and was given doxycycline for atypical coverage. He developed worsening encephalopathy and was intubated for airway protection. CSF profile revealed 255/mm3 WBC (77% neutrophils, 20% lymphocytes, 3% monocytes), 45/mm3 RBC, 61 glucose mg/dL (serum 126 mg/dL), and 96.1 mg/dL protein. Exposure history was significant for visiting family in central Arizona several weeks prior to presentation where he was exposed to mosquitos and two cats. He ate at a fast-food restaurant two days prior to presentation. He received three doses of COVID-19 vaccine. He was born and raised in Arizona and has remote travel to Mexico. Extensive studies (considering the risk factors above) identified the etiology of his encephalopathy as WNV encephalitis with positive serum PCR, elevated serum and CSF IgM with normal IgG. Unfortunately, the patient expired despite aggressive therapy. Discussion: This case represents three interesting challenges that we feel will be of interest to the conference attendees. The first is encephalopathy in a transplant recipient within one year of transplant requires a broad differential including donor-derived infections, opportunistic organisms that can cause meningoencephalitis, as well as knowledge of local and seasonal pathogens on the rise. With the monsoon season in 2021, Arizona rose to become one of the top ten states in the country with WNV cases. The second is management of a critically ill patient with meningitis and myasthenia gravis, since multiple agents for empiric therapy have been associated with worsening of or precipitating myasthenic crisis. Finally, supportive care is the mainstay of the management of WNV encephalitis and IVIG and adjustments in immunosuppression is controversial.