Reactions 1849, P235 - 3 Apr 2021 1

Reactions 1849, p235 - 3 Apr 2021 1

Immunosuppressants S BK viremia, BK virus cystitis and COVID-19: 2 case reports In a case report, two patients were described: A 59-year-old man developed BK viremia and COVID-19 following immunosuppression therapy with antithymocyte globulin, mycophenolic acid, tacrolimus and unspecified steroids, while a 53-year- old woman developed BK virus cystitis and COVID-19 following immunosuppression therapy with mycophenolic acid and tacrolimus [routes and dosages and time to reaction onsets not stated]. A 59-year-old man (Patient 1 from the article), who had hypertension with end-stage renal disease (ESRD) due to IgA nephropathy, underwent kidney transplantation in December 2019. His induction immunosuppression therapy included antithymocyte globulin for 4 days, associated with two unspecified steroids pulses. Maintenance immunosuppression therapy included tacrolimus, mycophenolic acid and unspecified steroids. He also received valganciclovir and cotrimoxazole as prophylaxis against for pneumocystis and CMV reactivation. After kidney transplantation, he developed post-transplant diabetes which was treated with unspecified antidiabetic therapy. At 2 months post-transplantation, serum creatininemia remained stable without proteinuria and tacrolimus trough level was 8.2 ng/mL. BK-virus screening was performed monthly during the first 6 months post- transplantation. A slight blood BK-virus replication was noted at 2 months post-transplantation. BK viraemia secondary to immunosuppression therapy was diagnosed. The man’s mycophenolic acid and unspecified steroids dosages were reduced. In March 2020, he was admitted to a hospital with cough and fever indicating COVID-19. Chest X-ray revealed bilateral interstitial opacities. Blood test on admission showed serum creatinine at 13.4 mg/L and total lymphocyte count of 170 /mm3. RT-PCR on nasopharyngeal swab showed a positive result for COVID-19, which was attributed to immunosuppression therapy. He did not receive specific treatment targeting COVID-19. At this time, BK viraemia had increased, indicating BK virus reactivation. Mycophenolic acid was interrupted and tacrolimus dose was drastically reduced to obtain trough level at 3.6 ng/mL. Within few days, clinical and biological evolution was favorable and he was discharged from hospital. After 15 days, during follow-up consultation, he had completely recovered from all symptoms except from persistent asthenia. Laboratory test result showed persistent lymphopenia and serum creatinine at 15 mg/L without proteinuria. After three months of COVID-19, despite interruption of mycophenolic acid and large decrease of tacrolimus dose (trough level around 5 ng/mL), BK viremia persisted. Therefore, possibility of reactivation of BK virus secondary to COVID-19 was considered. A 53-year-old woman (Patient 2 from the article), who had polycystic kidney disease, underwent kidney transplantation 15 years prior. Her medical history was significant for hypertension treated with unspecified ACE inhibitor. Her immunosuppression regimen included tacrolimus and mycophenolic acid. She developed lower urinary tract symptomatology with haematuria during the last months of 2019. Bladder biopsies demonstrated inflammation of bladder mucosa. BK-virus DNA was detected in urine. Therefore, she was diagnosed with BK-virus cystitis secondary to immunosuppression therapy. The woman’s mycophenolic acid dose was reduced which permitted disappearance of symptomatology. In March 2020, she consulted her general practitioner with symptoms of cough, fever and total anosmia. A diagnosis of COVID-19 was considered. Therefore, she was confined at home with daily teleconsultation and her immunosuppressive therapy was maintained identically. No specific treatment targeting COVID-19 was administered. Recovery was noticed in April 2020, with total disappearance of symptomatology. After few weeks, she showed the recurrence of lower urinary tract symptoms. Therefore therapy with mycophenolic acid was interrupted. Urine analysis was sterile. At this point, no BKV analysis was done. However, symptoms quickly disappeared with decreased immunosuppression. Therefore, possibility of reactivation of BK virus cystitis secondary to COVID-19 was considered. Masset C, et al. Resurgence of BK virus following Covid-19 in kidney transplant recipients. Transplant Infectious Disease 23: No. 1, Feb 2021. Available from: URL: http:// doi.org/10.1111/tid.13465 803550589