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Successful Treatment of Suspected Donor-derived Human Herpesvirus-8 Infection in a Liver Transplant Patient With Coronavirus Disease-19
Anna Maria Peri1, Bianca Magro2, Lorena van den Bogaart1,3, Alessia dalla Pria1,4, Paolo Giuffrida5, Andrea Gianatti6, Fabrizio Fabretti7, Anna Maria Barbui8, Alessandra Tebaldi1, Marco Rizzi1, and Stefano Fagiuoli2 | 1 Infectious Diseases Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy. | 2 Gastroenterology, Hepatology and Liver Transplantation, Department of Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy | 3 Infectious Disease Service, Lausanne University Hospital, Lausanne, Switzerland. | 4 National Centre for HIV Malignancy, Chelsea and Westminster Hospital, London, United Kingdom. | 5 Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Italy | 6 Pathology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy | 7 Intensive Care Unit III, Papa Giovanni XXIII Hospital, Bergamo, Italy | 8 Hematology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy | Transplantation 2021; epub
07/21/2021
New!Peer Reviewed Published DataSafetyViral infectionCase of the weekCase reportCOVID-19Critical CareCRRT (pre or post filter)Inflammatory parametersLiver failure
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Summary
CoW 29/2021 – This case reports on a 62-year-old male who received a liver allograft for hepatocellular carcinoma and 2 months later was admitted with SARS-CoV-2 interstitial pneumonia.
Case presentation
On admission, high-flow oxygen support, hydroxychloroquine and prophylactic enoxaparin were initiated, while his immunosuppressive regimen with tacrolimus and prednisone was continued
However, his condition rapidly deteriorated with worsening respiratory dysfunction, persistent fever, new onset of anuria, anasarca, and loss of consciousness
Blood tests showed high-inflammatory markers (D-dimer, C-reactive protein [CRP], Procalcitonin), severe thrombocytopenia, elevated interleukin-6 (IL-6), and acute kidney injury with elevated tacrolimus levels
A CT scan showed bilateral pneumonia, mediastinal lymphadenopathy, and splenomegaly
Plasma human herpesvirus-8 (HHV8)-DNA was significantly increased, and bone marrow biopsy showed polyclonal plasma cell proliferation
Serology at transplantation revealed: donor HHV8 IgG-positive and recipient IgG-negative
Tacrolimus was stopped
Despite maximum therapy, his condition rapidly deteriorated so rituximab (an anti-lymphocyte (CD20) monoclonal antibody) and continuous renal replacement therapy (CRRT) were started
Additionally, a CytoSorb adsorber was integrated into the system
Treatment
CytoSorb was used in conjunction with CRRT run in continuous veno-venous hemodia?ltration (CVVHDF) mode
Measurements
Overall clinical status
Inflammatory parameters
Level of consciousness
Acute kidney injury and thrombocytopenia
Results
The patient responded quickly with a significant clinical improvement over the following days
Inflammatory parameters decreased during and after combined treatment with CytoSorb and ritixumab (IL-6, CRP, procalcitonin, D-Dimer, ferritin)
He soon regained consciousness
Acute kidney injury and thrombocytopenia resolved
Patient Follow-Up
Three more rituximab doses were administered weekly
Once tacrolimus level was undetectable, everolimus was introduced
The patient was discharged after full recovery on day 35
Two months later, a bone marrow biopsy showed negative immunostaining for HHV8
The patient was found to be doing well with no adverse events observed at 1-year follow-up
Conclusions
In this case of a transplant recipient infected with the coronavirus (COVID-19), who developed life threatening organ dysfunction due to the onset of human herpes virus-8 (HHV8) infection, the use of CytoSorb in combination with rituximab was associated with a significant clinical improvement and a rapid improvement of the severe organ dysfunction
In the article, the authors discuss extracorporeal cytokine adsorption as a promising alternative to pharmacological inhibition of IL-6 in severe cases of COVID-19. They describe the fact that CytoSorb non-selectively blocks the immune cascade as an advantage, and in particular that it is possible to terminate CytoSorb at any time without long term effects that might harm immunocompromised patients.
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