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Letter to the Editor

COVID-19 in a Face Transplant Patient

Panayi, Adriana C. MD1; Kauke, Martin MD1; Pomahac, Bohdan MD1

Author Information
doi: 10.1097/TP.0000000000003789

Although solid organ transplant recipients have been reported to be at a higher risk of severe COVID-19, given the small number of face transplant recipients, there have yet to be similar reports in this patient population. Here, we describe a case of COVID-19 in a face transplant patient.

A 67-y-old female patient who had received a face transplant 10 y earlier was admitted to hospital with severe lack of appetite, diffuse abdominal pain, and diarrhea, 5 d after testing positive for SARS-CoV-2. There was no evidence of respiratory distress. A chest radiograph on the d of admission and chest computed tomography scan on hospital day 8 (D8) showed findings typical for COVID-19 pneumonia (Figures S1 and S2, SDC, http://links.lww.com/TP/C215). Laboratory test results were obtained daily (Table 1). The patient was on maintenance immunosuppression—mycophenolate mofetil (360 mg BD), prednisone (5 mg OD), and tacrolimus (2.5 mg BD). Her tacrolimus dose was adjusted on D3 (2 mg BD), D5 (1.5 mg BD), and D7 (1 mg BD) for supratherapeutic levels (target trough level 6–10 ng/mL) and acute kidney injury (AKI) as seen with a rise in creatinine levels.1 Her mycophenolate mofetil dose was adjusted on D4 (180 mg TD) due to leucopenia as well as AKI and reversed on D9 (360 mg TD) and kept at that level with improving WBC and AKI. For COVID-19, the patient was given intravenous Remdesivir (100 mg OD) on D9 and D10 and oral dexamethasone (6 mg OD) on D8. The patient was discharged 16 d after admission. Three months postrecovery, there has been no evidence of allograft rejection.

TABLE 1. - Laboratory values
Hospital day
Day ED visit 1 ED visit 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 10 PD
Mycophenolic acid (μg/mL) 2.41 3.65
d-Dimer (mg/L) 1.40 2.33 1.91 2.56 2.28 1.2
proBNP (pg/mL) 621 1928 2756 1952 1326 1518 2110 2082 2028
CRP (mg/L) 5.7 5.5 23.1 27.9 34.1 31.4 46.9 46.0 19.7
Procalcitonin (ng/mL) 0.08 0.09 0.08 0.08 0.1 0.14 0.1
WBC (×1000/µL) 3.4 5 5.2 4.2 4.3 3.7 4.8 5.6 3.6 3.6 5.6 6.1 7 9
Differential (%)
 Neutrophils 75.2 74.6 88.0 76.1 77.7 75.2 76.2 78.1 81.9 89.9 91.2 92.3 68.1
 Im Granulocytes 0.3 0.6 0.8 0.7 0.9 1.6 0.2 0.7 0 0.9 1 1 0.6
 Lymphocytes 15.2 15.6 5.7 16.1 15.3 16.2 18.4 14.7 7.8 3.7 3.9 4.0 21.2
 Monocytes 9.3 9.2 5.3 6.9 6.1 7 4.6 5.9 9.2 5.3 3.9 2.6 8.9
 Eosinophils 0 0 0 0 0 0 0 0.4 0 0 0 0 1.1
 Basophils 0 0 0.2 0.2 0 0 0.2 0.2 0 0.2 0 0.1 0.1
Absolute (Thou/µL)
 Neutrophils 2.52 3.74 4.6 3.2 3.3 2.8 3.6 4.4 2.9 5.1 5.6 6.5 6.1
 Im Granulocytes 0.01 0.03 0 0 0 0.1 0 0 1.1 0.1 0.1 0.1 0.1
 Lymphocytes 0.51 0.78 0.3 0.7 0.7 0.6 0.9 0.8 0.3 0.2 0.2 0.3 1.9
 Monocytes 0.31 0.46 0.3 0.3 0.3 0.3 0.2 0.3 0.3 0.3 0.2 0.2 0.8
 Eosinophils 0 0 0 0 0 0 0 0 0 0 0 0 0.1
 Basophils 0 0 0 0 0 0 0 0 0 0 0 0 0
 RBC (M/µL) 4.19 4.71 4.5 4.4 4.5 4 4.1 4.1 4.2 4.2 4 3.8 3.9 3.8
 Hemoglobin (g/dL) 12.4 13.3 13.1 12.7 12.9 11.7 12 11.7 11.9 12.2 11.4 11.3 11.2 10.8
 Hematocrit (%) 38.4 42.1 39.6 38.7 39.2 35.1 35.9 35.7 37 37.3 35.5 33.8 34.2 35.3
 MCV (fL) 92 89 88.4 87.2 86.9 87.3 86.7 87.7 87.5 89 89 88.3 88.6 93.9
 MCHC (g/dL) 32.3 31.6 33.1 32.8 32.9 33.3 33.4 32.8 32.2 32.7 32.1 33.4 32.7 30.6
 RDW-CV (%) 13.2 13.2 13.3 13.3 13.2 12.9 12.9 12.9 12.9 12.8 13 13 13.2 14.6
 Platelets (x1000/µL) 163 176 200 195 197 155 152 175 206 252 233 240 258 267
 MPV (fL) 11.8 12.2 11.3 11.4 11.6 11.1 11 11.5 11.5 11.4 10.9 11.1 11.3 11.5
 MCH (pg) 29.6 28.2 29.2 28.6 28.6 29.1 NV 28.7 28.1 29.1 28.6 29.5 29 28.7
 Sodium (mmol/L) 130 131 133 135 135 129 134 133 137 132 134 138 134 136 134 134 140
 Potassium (mmol/L) 5 4.9 5 4.6 4.2 3.9 4.4 4.5 4.1 3.9 4.1 5.0 4.7 4.8 5.3 5.3 4.2
 Chloride (mmol/L) 99 101 107 107 101 96 101 100 101 100 101 105 107 108 107 106 106
 CO2 (mmol/L) 21 18 12 16 20 20 22 21 24 18 18 20 19 20 20 21 23
 Anion gap 10 12 14 12 14 13 11 12 12 NV 15 13 8 8 7 7 11
 Glucose (mg/dL) 131 117 135 89 100 95 91 87 110 156 194 161 222 211 227 218 82
 BUN (mg/dL) 26 40 44 38 26 19 21 26 31 25 35 47 59 48 42 41 27
 Creatinine (mg/dL) 1.4 1.7 2.53 2.36 1.72 1.40 1.42 1.49 1.73 1.40 1.42 2.19 2.12 1.47 1.25 1.17 1.27
 Calcium (mg/dL) 9 8.8 7.9 8.1 7.9 7.6 8.1 8.3 8.5 8.1 8.6 8.8 8.2 8.1 8.2 8.5 8.7
 BUN/creatinine R 19 24 17.4 16.1 15.1 13.6 14.8 17.4 17.9 45 24.6 21.5 27.8 32.7 33.6 35.0 21.3
 eGFR (mL/min/1.73m2) 38 30 19 21 30 38 37 35 29 38 37 22 23 35 43 46 42
 ALP (U/L) 48 54 52 51 48 41 43 44 45 43 71
 AST (U/L) 25 26 49 37 40 56 48 46 30 26 18
 ALT (U/L) 21 21 29 25 23 26 27 30 55 42 22
 AST/ALT R 1.2 1.2 1.7 1.5 1.7 2.2 1.8 1.5 0.5 0.6 0.8
 Bilirubin (mg/dL) 0.4 0.3 0.2 0.3 0.5 0.5 0.3 0.3 0.3 0.3 0.7
Protein (g/dL)
 Total 5.9 6.4 5.8 5.5 5.3 5.2 5.3 5.6 4.9 5.2
 Albumin 4.1 4.1 3.5 3.3 3.3 3.1 2.9 2.9 2.7 3.5
 Globulin 1.8 2.3 2.3 2.2 2.0 2.1 2.4 2.7 2.2 1.7
 A/G R 2.3 1.8 1.5 1.5 1.7 1.5 1.2 1.1 1.2 2.1
Abnormal values shown in bold.
Abs, absolute; A/G, Albumin/Globulin; ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CO2, carbon dioxide; CRP, C-reactive protein; ED, emergency department; eGFR, estimated glomerular filtration rate; Im, immature; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; MCV, mean corpuscular volume; MPV, mean platelet volume; PD, postdischarge; proBNP, B-Type Natriuretic Peptide, Pro; R, ratio; RBC, red blood cell count; RDW-CV, red cell distribution width; WBC, white blood cell count.

Our case demonstrates that despite being on immunosuppression, face transplant recipients do not necessarily experience severe COVID-19. As was the case with our patient, some patients with COVID-19 may lack the expected pulmonary symptoms, while diarrhea may be the sole symptom.2

Patients with severe COVID-19 show prominent abnormalities including lymphocytopenia and leukopenia.3 Our patient had low lymphocytes across all days and high neutrophils on day of admission and D12–14 and had a normal WBC on most days. Prior studies have identified a correlation between high proBNP values and mortality.4 The proBNP values were elevated throughout hospitalization peaking on D3 and D9. Her impaired kidney function suggests that the likely cause for the elevated proBNP was decreased clearance.

Our patient’s immunosuppression was modified during her hospitalization, but her maintenance drugs were not discontinued. This may have been protective against severe disease as prior studies support that immunosuppression may help decrease the viral load. We noted a direct correlation between tacrolimus and creatinine kinase levels, with the highest tacrolimus level preceding the highest serum creatinine (Figure S3, SDC, http://links.lww.com/TP/C215). This reversible tacrolimus nephrotoxicity has been described in kidney transplantation.5

Regarding allograft viability, the patient displayed no clinical symptoms of rejection, including lack of erythema. The correlation between transplant rejection and viral infection is complex, with cytomegalovirus now recognized as the virus that has the highest correlation with allograft complications. Although further research is required to establish the relationship between COVID-19 and facial allotransplantation viability, our case serves as preliminary data that SARS-CoV-2 does not trigger rejection.

ACKNOWLEDGMENTS

The authors would like to thank all members of the multidisciplinary team both at Hartford Healthcare and Yale New Haven Health System for their excellent periprocedural care. We want to express gratitude to Kevin McComiskey for his dedication and enthusiasm in participating in the research activities of the patient. The presented study was approved by our hospital (Protocol 2019P002841). Although the patient has provided written informed consent for publication of identifying clinical photographs, no such photos are included.

REFERENCES

1. Kauke-Navarro M, Tchiloemba B, Haug V, et al. Pathologies of oral and sinonasal mucosa following facial vascularized composite allotransplantation. J Plast Reconstr Aesthetic Surg. 2021;741562–1571.
2. Liang W, Feng Z, Rao S, et al. Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus. Gut. 2020;691141–1143.
3. Guan W-j, Ni Z-y, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–1720
4. Sorrentino S, Cacia M, Leo I, et al. B-type natriuretic peptide as biomarker of COVID-19 disease severity: a meta-analysis. J Clin Med. 2020;9:E2957.
5. Katari SR, Magnone M, Shapiro R, et al. Clinical features of acute reversible tacrolimus (FK 506) nephrotoxicity in kidney transplant recipients. Clin Transplant. 1997;11:237–242.

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