Immunosuppressants
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Coronavirus disease 2019: 4 case reports In a case series, 4 patients (3 men and 1 woman) aged 53–74 years were described, who developed Coronavirus disease 2019 (COVID-19) during treatment with azathioprine, ciclosporin, mesalazine, mycophenolate mofetil, prednisone or tacrolimus [routes, dosages and durations of treatments to reactions onset not stated; not all outcomes stated]. Case 1: This report describes a 54-year-old man, who developed COVID-19 during treatment with tacrolimus and mycophenolate mofetil. The man with end-stage renal disease of unknown aetiology, underwent deceased donor renal transplantation 20 years previously. His course was complicated by transplant glomerulopathy with stage III chronic kidney disease and baseline serum creatinine of 1.9 mg/dL. His maintenance immunosuppressive medications included mycophenolate mofetil and tacrolimus. Additionally, his medical history was significant for hypertension and insulin-dependent diabetes mellitus; he had been receiving losartan. He had recent health-care contacts and was residing in an area with local SARS-CoV-2 transmission, but did not have any known direct contact with a case. His initial symptoms were insidious in onset and consisted of malaise, nausea, fever, chills, vomiting, dyspnoea, diarrhea and dry cough. One day after the start of symptoms, he was observed in a walk-in clinic, where chest X-ray and influenza testing were negative. His symptoms continued, and after 3 days with no resolution of fever, he was referred to an emergency department. On admission, he was febrile, with normal BP and heart rate. Oxygen saturation was found to be 93% on ambient air. Exam was remarkable for increased work of breathing and mild tachypnoea with clear lungs on auscultation. Initial laboratory studies showed a normal WBC count and differential acute-on-chronic kidney injury. A chest X-ray revealed a subtle consolidation in the left mid-lung. Nasopharyngeal swab real-time polymerase chain reaction (RT-PCR) testing was found to be positive for SARS-CoV-2 RNA. A diagnosis of COVID-19 was considered. To improve immune function, mycophenolate mofetil was interrupted on admission, and on the basis of worsened renal function, tacrolimus dose was decreased. His tacrolimus level reduced to 2.8 ng/mL prior to re-commencing the medication. On day 8 of admission, prednisone was added to his immunosuppression regimen to provide further immunosuppression in the setting of the reducing tacrolimus level. His losartan was interrupted on admission because of acute kidney injury, which was ascribed to volume depletion from decreased oral intake, vomiting and diarrhoea. Empiric azithromycin and ceftriaxone were administered for community acquired pneumonia, although concomitant bacterial superinfection or infection ultimately were not suspected. The severity of his symptoms peaked on day 5 of admission and illness on day 8 of admission. His oxygen saturation reduced to 88% on 2 L/min nasal cannula. He needed a maximum supplemental oxygen support of 4 L/min via nasa
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