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.