Immunosuppressants
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Immunosuppressants COVID-19 and secondary infections: 3 case reports
A case report described three men aged 37–59 years, who developed COVID-19 infections following immunosuppression therapy with methylprednisolone, mycophenolate, tacrolimus or unspecified glucocorticoids following liver transplantation. All patients additionally developed secondary bacterial or fungal infections (opportunistic infections), including Candida albicans and Pseudomonas aeruginosa infections [routes not stated; not all dosages stated]. Patient 1: A 59-year-old man, whose medical history was notable for obstructive jaundice, hepatitis B virus infection and hepatocellular carcinoma, underwent liver transplantation. Maintenance immunosuppression comprised tacrolimus and mycophenolate. However, about 2 years and 9 [sic] post-transplant, he developed COVID-19 infection. He was hospitalised with a fever, accompanied by jaundice, splenomegaly and ascites. Tests revealed abnormalities in WBC count, lymphocyte count, CRP, total bilirubin, ALT and GGT. Chest CT scan revealed bilateral ground-glass opacities on day 1. He developed respiratory failure on day 4. Therefore, he started receiving methylprednisolone on day 4. Chest CT scan revealed significant worsening of bilateral lung inflammation on day 12. Further, blood cultures grew Candida albicans, while alveolar lavage and pleural fluid tested positive for Pseudomonas aeruginosa on day 12. Bile duct pus was found to be positive for Pseudomonas aeruginosa on day 23. Tacrolimus and mycophenolate were maintained. He received interferon-α, umifenovir [arbidol] and lopinavir/ritonavir off-label for the COVID-19 infection. In addition, he received IV immune globulin. He also received piperacillin/tazobactam on day 1, caspofungin and cefoperazone/sulbactam on day 12, and meropenem and voriconazole on day 23. Repeat RT-PCR tests for COVID-19 were found to be negative on days 33 and 35. However, he developed multiple organ failure on day 37, and in spite of antibacterial therapy, he succumbed to secondary bacterial and fungal infections on day 45. Patient 2: A 50-year-old man, whose medical history was notable for hepatitis B cirrhosis, underwent liver transplantation. Maintenance immunosuppression comprised tacrolimus monotherapy at a mean dose of 0.03 mg/kg/day. However, about 2.5 years post-transplant, he developed COVID-19 infection. He was hospitalised with a fever, and tests revealed abnormalities in WBC count, lymphocyte count and CRP. Chest CT scan revealed multiple peripheral patchy ground-glass shadows in both lungs on day 1. Opportunistic infections were suspected; hence, he started receiving cefoperazone on day 1. Tacrolimus was discontinued from day 2–day 29 (for 4 weeks), and he started receiving systemic methylprednisolone from day 2. He developed progressive dyspnoea on day 5. Chest CT scan revealed mixed diffuse ground-glass opacities with multifocal patchy consolidation involving both lungs and bronchiectasis in left lower lobe on day 8. He received interferon-α, umifenovir [ar
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