Case report: COVID-19 infection of a transplanted heart simulating cellular rejection

ABSTRACT

Contemporary reports showed that solid organ transplanted patients who contract severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a high mortality rate. There are sparse data about recurrent cellular rejections and the immune response to SARS-CoV-2 virus in patients following heart transplantation. Herein, we report a case of a 61-year-old male post-heart transplant patient who tested positive for COVID-19 and developed mild symptoms four months after transplantation. Thereafter, a series of endomyocardial biopsies showed histological features of acute cellular rejection despite optimal immunosuppression, good cardiac functions and hemodynamic stability. Demonstration of SARS-CoV-2 viral particles by electron microscopy in the endomyocardial biopsy confirmed the presence of the virus in the foci of the cellular rejection, pointing to a possible immunologic reactions to the virus. To our knowledge, there is limited information regarding the pathology of COVID-19 infection in immunocompromised heart transplant patients, and there are no well-established guidelines for the treatment of such patients. Based on the demonstration of SARS-CoV-2 viral particles within the myocardium, we concluded that myocardial inflammation that can be seen on endomyocardial biopsy may be attributed to the host immune response to the virus which mimics acute cellular rejection in newly heart transplant patients. We report this case to increase the awareness of such events post-transplantation, and to gain more knowledge regarding the management of patients with ongoing SARS-CoV-2 infection which proved to be challenging.