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Introduction: The COVID-19 pandemic demands an urgent response from the transplant community in order to protect our vulnerable patient population We present the rare case of COVID-19 in a combined liver-kidney transplant recipient from the United States Case Report: The patient is a 77 year-old diabetic woman who presented to our transplant center with decompensated cryptogenic cirrhosis She underwent combined liver-kidney transplant Postoperatively, her liver enzymes normalized, and she no longer required dialysis She was discharged to a rehabilitation facility 12 days after transplant (POD #12) On POD #13, the patient had rehabilitation sessions with an occupational therapist who later tested positive for COVID-19 This day is presumed to be her first exposure, and subsequent days will be referred to as \'post-exposure days\' (PEXD) On PEXD #9 (POD #22), the patient developed a fever of 103 degrees, accompanied by chills and nausea However, no dyspnea, cough, or respiratory complaints were present at presentation Other than an elevation in alkaline phosphatase of 168 U/L, her liver enzymes and creatinine were normal (Table 1) Chest CT only showed trace right pleural effusion with no pulmonary infiltrates, no ground-glass opacification, and no consolidation (Figure 1) Abdominal CT revealed a 20 x 15 cm fluid collection surrounding the left kidney graft Mycophenolate mofetil was discontinued, but prednisone and tacrolimus were continued Tacrolimus dosing was adjusted to achieve a target daily through level range of 6 - 10 ng/mL The following morning (PEXD #10), the patient underwent percutaneous drainage of her perinephric abscess Her fever and pain subsided following intervention On PEXD #11, the patient\'s COVID-19 test resulted as positive Isolation precautions were maintained Chest X ray was clear She had no dyspnea or cough, and she maintained oxygen saturation of 96-100% on room air A five-day course of treatment with oral hydroxychloroquine at 400 mg was planned, and started on PEXD #11 However, the patient had a significant elevation in liver enzymes immediately following treatment initiation The drug was discontinued on PEXD #13 The patient\'s liver enzymes improved following drug cessation We decided to initiate treatment with azithromycin on PEXD #15, completing a five-day treatment course The patient remained asymptomatic and did not require oxygen therapy at any point On PEXD #23 (hospital day 14, POD# 36), the patient was discharged home MMF was not restarted Tacrolimus and steroid taper were continued as scheduled Allograft function and chest imaging prior to discharge were normal Conclusions: Calcineurin inhibitors interfere with the cyclophilins and FKBP required by various coronaviridae for replication Along with steroids, they also dampen the cytokine storm The antiviral potential of calcineurin inhibitors and steroids warrants further investigation into their role as viable therapy for COVID-19
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