A 68-Year-Old Lung Transplant Recipient With Shortness of Breath, Weight Loss, and Abnormal Chest CT

Abstract

A 68-year-old man presented to our ED with shortness of breath, weakness, and a 25-lb unintentional weight loss. He had undergone bilateral lung transplantation (cytomegalovirus [CMV]: donor+, recipient+; Epstein-Barr virus: donor+; recipient+) for idiopathic pulmonary fibrosis (IPF) 18 months prior. His posttransplant course was fairly unremarkable until 1 month earlier, when he was admitted for breathlessness and weakness. CT of the chest during that admission revealed mild intralobular and interlobular septal thickening. A bronchoscopy with BAL and transbronchial biopsies did not show acute cellular rejection, but the BAL fluid was positive for coronavirus. His cortisol level was undetectable; he was diagnosed with adrenal insufficiency and fludrocortisone was initiated. He was taking prednisone, tacrolimus, and everolimus for immunosuppression and valganciclovir, itraconazole, and trimethoprim-sulfamethoxazole for antimicrobial prophylaxis. His 25-lb weight loss occurred over the span of just one month.

COVID‐19 and the use of immunomodulatory and biologic agents for severe cutaneous disease: An Australian/New Zealand consensus statement

“…Case reports also describe atypical presentations of coronavirus infections in immunocompromised hosts, including prolonged incubation periods, persistent asymptomatic viral shedding, diarrhoea, weight loss and encephalitis as primary manifestations. 13,14,15,16 Initial Chinese observational studies on COVID-19 did not report a high rate of immunocompromised patients in severe hospitalised cases; however, this is likely underestimated due to a difference in demography compared to Western populations. Overall, there is currently insufficient evidence to suggest that COVID-19 infection is aggravated by immunomodulators used in skin disease; however, all COVID-19 infections should be considered serious and a precautionary approach is necessary.…”

“…severe inflammatory bowel disease and cancer). Case reports also describe atypical presentations of coronavirus infections in immunocompromised hosts, including prolonged incubation periods, persistent asymptomatic viral shedding, diarrhoea, weight loss and encephalitis as primary manifestations 13,14,15,16 …”