Severe COVID-19 after liver transplantation, surviving the pitfalls of learning on-the-go: Three case reports

Abstract

Background: The novel coronavirus 2019 (COVID-19) pandemic has dramatically transformed the care of the liver transplant patient. In patients who are immunosuppressed and with multiple comorbidities, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with increased severity and mortality. The main objective of this report is to communicate our experience in the therapeutic management of SARS-CoV-2 infection in 3 liver transplant patients. Secondly, we stress the management and investigation of the contagious spreading into a liver transplant ward.

Case summary: The patients were two women (aged 61 years and 62 years) and one man (aged 68 years), all of them having recently received a liver transplant. All three patients required intensive care unit admission and invasive mechanical ventilation. Two of them progressed severely until death. The other one, who received tocilizumab, had a good recovery. In the outbreak, the wife of one of the patients and four healthcare professionals involved in their care were also infected.

Conclusion: We illustrate in detail the evolution of a nosocomial COVID-19 outbreak in a liver transplant ward. We believe that these findings will contribute to a better understanding of the natural history of the disease and will improve the treatment of the liver transplant patient with COVID-19.

Keywords: COVID-19; Case report; Cross infection; Liver transplantation; Nosocomial infection; SARS-CoV-2.

Figure 1

Clinical evolution of each case in a chronological perspective. A: (Case 1) Although the first reverse transcription polymerase chain reaction of severe acute respiratory syndrome coronavirus 2 was negative for the first few days, dyspnea became worse requiring intensive care unit admission. A single dose of lopinavir/ritonavir was administered on day 7; B: (Case 2) A dose of tocilizumab was administered on day 33. The patient improved progressively until he was discharged home; and C: (Case 3) A dose of tocilizumab was administered on day 28. The patient suffered a progressive worsening. A tracheoesophageal fistula was detected and an oesophageal prosthesis was placed. In addition, a venovenous extracorporeal membrane oxygenation was implemented to improve the patient's oxygenation. BAL: Bronchoalveolar lavage; ICU: Intensive care unit; IMV: Invasive mechanical ventilation; LPV/r: Lopinavir/ritonavir; NIV: Non-invasive ventilation; RT-PCR: Reverse transcription polymerase chain reaction; vv-ECMO: Venovenous extracorporeal membrane oxygenation.

Figure 2

Epidemiological evolution of severe acute respiratory syndrome coronavirus 2 outbreak in our transplant division, according to the presence or absence of symptoms, the positivity of the reverse transcription polymerase chain reaction, and the patients’ locations each day from symptoms onset. In orange, when suggestive symptomatology of novel coronavirus 2019 was present. In green, when the reverse transcription polymerase chain reaction of severe acute respiratory syndrome coronavirus 2 was positive. In red, when reverse transcription polymerase chain reaction was performed but was negative. W: Admitted to the ward; I: Admitted to the intensive care unit.