SARS-CoV-2 Re-Infection in a Lung Transplant Recipient

INTRODUCTION: Since the onset of the SARS-CoV-2 pandemic, increasing evidence has shown waning immunity after initial SARS-CoV-2 infection, and re-infection in patients with a prior history of COVID-19 has been reported. We report a case of SARS-CoV-2 re-infection in a lung transplant recipient 3 months after initial illness. CASE REPORT: The patient is a 56-year-old man with a history of bilateral lung transplant in August 2018 for idiopathic pulmonary fibrosis. His post-transplant course was complicated by insulin-dependent diabetes mellitus (HbA1c 5.8%), chronic renal insufficiency (eGFR nadir 48 mL/min/1.73m(2)), and peripheral arterial disease requiring bilateral below-knee amputations. At the time of transplant, he was induced with basiliximab and remained on standard 3-drug immunosuppression with mycophenolate mofetil (500 mg BID), prednisone (5 mg daily), and tacrolimus. He contracted SARS-CoV-2 from his wife and tested positive for the virus on July 2, 2020 after presenting to the emergency department (ED) with headache, chills, nausea, body aches, shortness of breath, and generalized weakness. His oxygen saturation and chest X-ray were normal, and he was therefore discharged from the ED to recover at home. His symptoms resolved 17 days after diagnosis and serial SARS-CoV-2 testing via nasal washing were positive on July 16, 2020 and negative on July 30, 2020 and August 11, 2020. In addition, on October 21, 2020, he tested positive for SARS-CoV-2 antibodies (3.41, positive: index ≥1.4). On October 23, 2020, he presented to the ED with generalized chest pain, low-grade fever (100.1F), dyspnea, and weakness. His nasal swab was positive for SARS-CoV-2 and CT of the chest showed bibasilar ground-glass opacities consistent with atypical infection vs. atelectasis. His labs were notable for a CRP of 132 mg/L, ferritin of 2,307 ng/mL, LDH 304 units/L, D-dimer 240 ng/mL, and procalcitonin of 0.05 ng/mL. He was admitted for monitoring and treated with remdesivir, corticosteroids, and anticoagulation. SUMMARY: We present a case of SARS-CoV-2 re-infection 3 months after initial illness in a lung transplant recipient living in a high-incidence area. Unexpectedly, recurrent infection occurred despite development of SARS-CoV-2 antibodies. This case speaks to the vulnerability of this patient population to COVID-19 and the need for ongoing precautions to prevent infection even among patients who have seroconverted.