(665) Covid-19 Infection and Subsequent Development of Antibody-Mediated Rejection in an Infant Post-Lung Transplant

INTRODUCTION: In lung transplant recipients, respiratory viral infections trigger a robust immune response and can increase the risk of developing antibody-mediated rejection (AMR). We report an infant who contracted COVID-19 and subsequently developed AMR. CASE REPORT: A 4-month old was transplanted due to surfactant protein B deficiency requiring support with mechanical ventilation via tracheostomy. Basiliximab was used for induction and post-surgery required 2 days of VV-ECMO due to primary graft dysfunction. He was successfully decannulated and weaned to room air by discharge. Five months post-transplant he was diagnosed with COVID-19 infection with associated hypoxemia, fever, and rhinorrhea. He received only 3 days of remdesivir due to hepatotoxicity, 10 days of dexamethasone, and was weaned to room air prior to discharge. He continued to test positive for COVID-19 up to 2 months after initial diagnosis, required multiple readmissions, and ultimately diagnosed with AMR as detailed in the timeline below. AMR treatment was promptly initiated and included rituximab, methylprednisolone, plasmapheresis, bortezomib, and 6 months of high-dose (1 g/kg) IVIG infusions. His DSA remained positive, but with significantly reduced MFI to 3,865 and a weak de novo DSA with MFI 1,133 against DRw-2. By the completion of AMR treatment his chest CT showed marked decrease in bilateral airspace disease, had only focal and weak C4d positivity on histopathology and he had been weaned to room air. SUMMARY: COVID-19 in lung transplant recipients may stimulate an immune response that promotes development of AMR. Prompt diagnosis of AMR is crucial in preventing further allograft dysfunction with initiation of early and extensive treatment.