e4n6dn2d

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?:abstract	A 50-year-old man developed COVID-19 infection while receiving immunosuppressive therapy with basiliximab, prednisone, tacrolimus and mycophenolate mofetil Later, he received off-label treatment with tocilizumab and hydroxychloroquine for the COVID-19 infection [not all dosages and routes stated] The man had a history of end-stage non-ischaemic cardiomyopathy, diabetes and chronic kidney disease Initially, he underwent left ventricular assist device implantation (LVAD) as a bridge to cardiac transplantation, which was complicated by late-onset post-LVAD right ventricular dysfunction along with inotrope dependence and severe cardiorenal syndrome after two years Eventually, on 28 February 2020, he underwent heart transplantation, which was followed by renal transplantation on the following day The procedures were completed uneventfully Induction immunosuppression therapy included basiliximab, and maintenance immunosuppression included tacrolimus, prednisone and mycophenolate-mofetil [initial dosages not stated] However, 25 days after the transplant, he presented with asymptomatic atrial flutter, which spontaneously converted to sinus rhythm Examinations showed BP of 128/75mm Hg, HR of 95 beats/minute and temperature of 36 8°C Initial cardiopulmonary examination was unremarkable and endocardial biopsy showed negative result for rejection After 48 hours, he developed rhinorrhea and cough, and subsequently tested positive for COVID-19 infection [duration of treatment to reaction onset not stated] He was otherwise asymptomatic The man\'s ongoing prednisone dose was reduced to 30mg, tacrolimus was continued and mycophenolate mofetil dose was reduced to 50% Off label treatment with hydroxychloroquine was started As his condition remained stable in the following three days, he was discharged to isolation at home with pulse oximetry and scheduled daily telemedicine assessments After 3 days, he presented to the emergency department with rapidly progressive respiratory distress and hypoxia Chest radiography showed extensive bilateral airspace opacities Laboratory tests showed elevated ferritin levels (648 ng/mL), CRP 74 9 mg/L and D-dimer (4 81 µg/mL) Differential diagnosis at this time included COVID-19 infection, heart transplant rejection, viral myocarditis and stress cardiomyopathy ECG showed no signs of ST-segment changes, and high sensitivity troponin concentration was mildly elevated (34 pg/mL) Transthoracic echocardiography showed biventricular systolic dysfunction with left ventricle ejection fraction of 40% and moderately depressed right ventricular function Based on the examinations, COVID-19 infection and related stress injury was confirmed He was shifted to ICU He required intubation and mechanical ventilation due to worsening respiratory status Lung protective ventilation along with deep sedation, epoprostenol and paralytics were started for severe acute respiratory distress syndrome After receiving consent, he was administered one dose of IV tocilizumab 400mg (off-label treatment) For possible hospital-acquired pneumonia, azithromycin and unspecified broad spectrum antibacterial were started Hydroxychloroquine was continued Ongoing prednisone therapy was changed to stress dose IV hydrocortisone Tacrolimus was changed to continuous infusion with target steady state level of 10-12 and mycophenolate mofetil was stopped Unspecified diuretics were administered for the maintenance of daily negative fluid balance He also developed transient mild acute kidney injury, which resolved without any additional intervention His end-organ functions remained normal without Subsequent improvement was noted in his respiratory status On day 7, he was extubated and oxygen therapy was stopped by day 12 On day 14, he was discharged During weekly telemedicine assessment (after discharge), gradual improvement was reported Mycophenolate mofetil was restarted During the last follow up examination (36 days after the initial diagnosis of COVID-19 infection), tests continued to show positive result for OVID-19 infection
?:creator	<https://research.tib.eu/covid-19/entity/Anonymous%2C>
?:journal	Reactions_Weekly
?:license	unk
?:publication_isRelatedTo_Disease	<https://research.tib.eu/covid-19/entity/COVID-19>
?:source	WHO
?:title	Antivirals/immunosuppressants
?:type	<https://research.tib.eu/covid-19/vocab/Publication>
?:who_covidence_id	#691644
?:year	2020

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?:abstract

A 50-year-old man developed COVID-19 infection while receiving immunosuppressive therapy with basiliximab, prednisone, tacrolimus and mycophenolate mofetil Later, he received off-label treatment with tocilizumab and hydroxychloroquine for the COVID-19 infection [not all dosages and routes stated] The man had a history of end-stage non-ischaemic cardiomyopathy, diabetes and chronic kidney disease Initially, he underwent left ventricular assist device implantation (LVAD) as a bridge to cardiac transplantation, which was complicated by late-onset post-LVAD right ventricular dysfunction along with inotrope dependence and severe cardiorenal syndrome after two years Eventually, on 28 February 2020, he underwent heart transplantation, which was followed by renal transplantation on the following day The procedures were completed uneventfully Induction immunosuppression therapy included basiliximab, and maintenance immunosuppression included tacrolimus, prednisone and mycophenolate-mofetil [initial dosages not stated] However, 25 days after the transplant, he presented with asymptomatic atrial flutter, which spontaneously converted to sinus rhythm Examinations showed BP of 128/75mm Hg, HR of 95 beats/minute and temperature of 36 8°C Initial cardiopulmonary examination was unremarkable and endocardial biopsy showed negative result for rejection After 48 hours, he developed rhinorrhea and cough, and subsequently tested positive for COVID-19 infection [duration of treatment to reaction onset not stated] He was otherwise asymptomatic The man\'s ongoing prednisone dose was reduced to 30mg, tacrolimus was continued and mycophenolate mofetil dose was reduced to 50% Off label treatment with hydroxychloroquine was started As his condition remained stable in the following three days, he was discharged to isolation at home with pulse oximetry and scheduled daily telemedicine assessments After 3 days, he presented to the emergency department with rapidly progressive respiratory distress and hypoxia Chest radiography showed extensive bilateral airspace opacities Laboratory tests showed elevated ferritin levels (648 ng/mL), CRP 74 9 mg/L and D-dimer (4 81 µg/mL) Differential diagnosis at this time included COVID-19 infection, heart transplant rejection, viral myocarditis and stress cardiomyopathy ECG showed no signs of ST-segment changes, and high sensitivity troponin concentration was mildly elevated (34 pg/mL) Transthoracic echocardiography showed biventricular systolic dysfunction with left ventricle ejection fraction of 40% and moderately depressed right ventricular function Based on the examinations, COVID-19 infection and related stress injury was confirmed He was shifted to ICU He required intubation and mechanical ventilation due to worsening respiratory status Lung protective ventilation along with deep sedation, epoprostenol and paralytics were started for severe acute respiratory distress syndrome After receiving consent, he was administered one dose of IV tocilizumab 400mg (off-label treatment) For possible hospital-acquired pneumonia, azithromycin and unspecified broad spectrum antibacterial were started Hydroxychloroquine was continued Ongoing prednisone therapy was changed to stress dose IV hydrocortisone Tacrolimus was changed to continuous infusion with target steady state level of 10-12 and mycophenolate mofetil was stopped Unspecified diuretics were administered for the maintenance of daily negative fluid balance He also developed transient mild acute kidney injury, which resolved without any additional intervention His end-organ functions remained normal without Subsequent improvement was noted in his respiratory status On day 7, he was extubated and oxygen therapy was stopped by day 12 On day 14, he was discharged During weekly telemedicine assessment (after discharge), gradual improvement was reported Mycophenolate mofetil was restarted During the last follow up examination (36 days after the initial diagnosis of COVID-19 infection), tests continued to show positive result for OVID-19 infection

?:creator