Case presentation
A 27-year-old man known case of hypertension and end-stage renal disease underwent a diseased kidney transplant due to IgA nephropathy on December 9, 2020.
The patient had no specific past medical history. His immunosuppressive regimen consisted of Prograf 12 mg orally twice daily and Myfortic 360 mg three times daily, and there was no sign of acute rejection.
Three days after transplantation was admitted to BueAli hospital in Shiraz, complaining of a high-grade fever (up to a maximum of 39.2 °C) for two days. This fever was followed by cough and shortness of breath. All his immunosuppressants were reduced as the doctor advised.
On admission, a chest computed tomography (CT) scan was done for him to roll out covid-19, which showed ground-glass opacities in multiple areas of both lungs (Figure 1). Laboratory testing showed a mild decrease in white blood cell count and decreased absolute lymphocyte count (1000 × 106 /L ). One day after the admission, serum creatinine raised to 7 mg/dl.
For detection of SARS-CoV- 2, a nasopharyngeal swab specimen was obtained and sent to the laboratory. COVID-19 was diagnosed for our patient according to the positive result of SARS-CoV-2, which was confirmed by real-time reverse transcription-polymerase chain reaction (RT-PCR) and CT findings.
Combination therapy was initiated with methylprednisolone (40 mg daily) and remdesivir for two days to inhibit virus replication. Four days after admission, Due to the rise of creatinine to 7 mg/dl, a renal biopsy was done to role out delayed graft function or rejection. Renal biopsy showed acute T cell-mediated rejection grade 2b due to arteritis in three vessels and moderate acute tubular injury with tubular necrosis (Figure 2).
His immunosuppressive regimen consisted of Prograf 12 mg orally twice daily and Myfortic 360 mg three times daily was resumed. High-flow nasal oxygen administration was ordered for him, and he underwent hemodialysis three times. During the clinical course, the patient’s symptoms were resolved, and body temperature decreased to 37.1 °C, and respiratory symptoms such as cough and shortness of breath disappeared.
The lymphocyte count and serum creatinine improved. The kidney function also got better during therapy. On day 9, the second chest CT scan showed significant improvement, and bilateral ground-glass opacities decreased.
Based on the persistent negative results of SARS-CoV-2 RT-PCR on days 9 and 11 and decreased lung lesions, the patient was discharged on day 13. To date, the patient follow-up has been in good health at home for four months.