Case Report of Donor Transmitted SARS-CoV-2 Infection During Lung Transplantation

INTRODUCTION: Avoiding SARS-CoV-2 infection in the peri-operative period is a challenge for lung transplantation during the COVID19 pandemic. Testing donor lung BAL samples for SARS-CoV-2 as part of pre-transplant workup may avoid donor-derived infections. CASE REPORT: A 36-year-old woman with interstitial lung disease secondary to desquamatous interstitial pneumonia during infancy underwent bilateral lung transplant. She was highly allosensitized (cPRA >89%, ccPRA 97%) prompting intra-operative plasmapheresis (PLEX) and rabbit thymoglobulin induction immunosuppression. Post-operatively, her immunosuppression consisted of institution-standard tacrolimus, mycophenolate, and methylprednisolone. For HLA desensitization belatacept, rituximab, intravenous immunoglobulin (IVIG), and carfilzomib regimens were added. She was extubated post-op day 2. Her course was complicated by worsening hypercarbia, hypoxia and respiratory secretions. Post-op day 11, she was reintubated with tracheostomy placement. Chest imaging showed bilateral heterogeneous pulmonary opacities. BAL sampling was positive for SARS-CoV-2 with concern for donor transmission given adherent hospital precautions. Pre-transplant donor and recipient nasopharyngeal (NP) SARS-CoV-2 screenings were negative. Donor transmission was confirmed by positive PCR testing of banked pre-operative donor lung BAL samples. Dexamethasone and remdesivir were started. Tacrolimus and mycophenolate were continued for immunosuppression. She developed acute antibody-mediated rejection (AMR) with new donor specific antigens (DSA) likely related to her SARS-CoV-2 infection. Her AMR was managed with IVIG and PLEX x 10 with PLEX followed by SARS-CoV-2 convalescent plasma. Her DSA's resolved and ventilatory support was weaned. She was discharged home post-op day 56 and was doing well on room air 6 months out. SUMMARY: This case emphasizes a potential to miss donor SARS-CoV-2 infection in standard pre-operative evaluation. Despite absence from the NP mucosa viable SARS-CoV-2 virions may be present in donor lung tissue, increasing risk of infection to recipients. Peri-transplant SARS-CoV-2 infection carries a high risk of morbidity. Of note, our case occurred prior to the UNOS mandate for donor lung SARS-CoV-2 screening by lower respiratory sampling. This mandate will decrease risk for similar cases in the future.