The diagnostic dilemma of covid-19 pneumonia in a kidney transplant patient-a case report

ABSTRACT

Introduction: On March 11, 2020, the WHO declared COVID-19 as global pandemic. Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a new strain of coronavirus. By 20May 2020 there have been nearly five million confirmed cases with COVID-19 and more than 320.000 deaths worldwide. There is still limited data about the course of the disease in transplant patients. Some reports suggest that immunosuppression can have a protective role in patients with COVID-19, however other reports suggest an increased mortality in transplant patients. The specificity and sensitivity of diagnostic tests for SARSCoV-2 in immunosuppressed patients are also unclear at this point. Methods: We present a case report of diagnostic difficulties of SARS-CoV-2 in a female AB0-incompatible kidney transplant patient with severe COVID-19 pneumonia requiring intubation and mechanical ventilation. Results: Albeit she presented with typical symptoms for at least two weeks, PCR of two nasopharyngeal swabs and one throat wash were negative. Ultimately, typical findings on CT scans and positive stool samples confirmed the diagnosis before bronchoscopy was done and BAL tested positive. Despite immunosuppressive therapy was reduced her condition worsened. Mechanical ventilation was necessary for 17 days, however she was able to recover and could be discharged. Kidney function remained stable without renal replacement therapy. Conclusion: Our findings suggest that-especially in areas or situations where bronchoscopy and CT scans might not be available-stool testing for SARSCoV-2 might be of additional value to identify, isolate and treat COVID-19 patients. Taken together, this case highlights the importance of different diagnostic approaches when dealing with transplant patients to reach a proper diagnosis of COVID-19. Invasive procedures bear the potential of worsening the clinical course. Non-invasive stool testing might be an interesting supplemental diagnostic method. Moreover, at this point there is only scarce information published in relation to the extent of COVID-19 in transplant patients. Our case shows that reduced immunosuppression and IVIg-therapy was sufficient for a complete recovery with functioning graft.