POST-MORTEM MOLECULAR INVESTIGATIONS OF SARS-COV-2 IN AN UNEXPECTED DEATH OF A RECENT KIDNEY TRANSPLANT RECIPIENT

ABSTRACT

Introduction: Solid organ transplant (SOT) recipients are vulnerable to severe infection during induction therapy. We report a case of a 67-year-old male who died unexpectedly 10 days after receiving a kidney transplant (KTx) on February 10, 2020. There was no clear cause of death, but COVID-19 was considered, retrospectively, as the death occurred shortly after the first confirmed case of COVID-19 in Canada. We confirmed the presence of SARS-CoV-2 components in the allograft and patient lung tissue using immunohistochemistry (IHC) for SARS-CoV-2 spike (S) protein and RNA scope in situ hybridization for SARS-CoV-2 RNA. Results were confirmed with the FDA EUA-approved Bio-Rad SARS-CoV-2 ddPCR for the kidney specimen. Our case highlights the importance of patient autopsies in an unfolding global pandemic and demonstrates the utility of molecular assays to diagnose SARS-CoV-2 post-mortem. SARS-CoV-2 infection during induction therapy may portend a severe or fatal clinical outcome. We also suggest COVID-19 may be transmittable via KTx. Methods: We acquired autopsy specimens of the allograft and lung tissue for analysis by IHC (Figure 4A). RNA scope in situ hybridization and immunohistochemistry verified the presence of viral particles. Results were confirmed with RT-PCR and dd-PCR. Results: Remarkably, antibodies directed against SARS-CoV-2 S protein were positive in the allograft and native lung tissue of the patient (Figure 4B). RNA scope in situ hybridization, RNA scope in situ hybridization was used to detect SARS-CoV-2 RNA in the allograft (Figure 4C) as previously described.3,7 With both IHC and RNAscope, we noted very few viral particles, with more in the donor kidney compared to native lung tissue. To confirm this finding, we used RT-PCR, but were unable to detect SARS-CoV-2 RNA (data not shown). Next, we turned to a FDA-EUA clinically validated BioRad ddPCR assay approved for human diagnosis,previously used to detect SARS-CoV-2 RNA in RT-PCR negative samples.Using ddPCR, we confirmed SARS-CoV-2 nucleocapsid N1 gene in the allograft (Figure 5). A smaller signal was observed in lung tissue, but lower than the clinically validated threshold (Figure 5). Conclusions: Using three methods of viral protein and/or RNA detection we present a COVID-19 positive patient who died on February 10, 2020 which precedes the first confirmed case in Alberta, Canada and first Canadian COVID-19 fatality previously established as a travel-related case on March 5, 2020 and nursing home death on March 9, 2020, respectively. Our patient demonstrates the possibility of a severe adverse outcome for COVID-19 infection during induction therapy and the potential for SARS-Cov-2 renal allograft invasion mediated SOT transmission. This case carries significant epidemiologic consequences and highlights the vital role of autopsy in an unfolding pandemic in providing valuable diagnostic information. These sensitive methods can be applied to future disease outbreaks in the absence of pre-mortem testing. No conflict of interest