Fatal Covid-19 vasoplegic shock in a recipient few hours before double lung transplantation in high emergency.

SARS‐Cov2 outbreak has deeply impacted French lung transplant programs by the decreased number of lung donors, the scarcity of intensive care unit (ICU) beds, and most importantly, the assumed worse prognosis of Covid‐19 in recipients during perioperative period. Despite no evidence has been published to suggest that lung transplant recipients were at high risk of acquiring the virus or developing severe Covid‐19, immunosuppression may worsen the prognosis of such infection in patient transplanted for end‐staged lung diseases.

We present the case of a 59‐year‐old patient with pulmonary fibrosis who has been listed for lung transplantation (LTx) in March 2020. Two weeks after listing, the patient presented with severe respiratory compromise without fever. Chest CT did not show signs of SARS‐Cov2 pneumonia. Nasal, tracheal, and rectal SARS‐Cov2 PCR were repeated three times daily before ICU admission, and all came back negative. No other infectious triggers have been elucidated so far. Patient condition continued to worsen leading to ECMO implantation followed by tracheal intubation. Seven days later, one of the ten French transplant centers had the opportunity to transplant the patient despite ICU beds scarcity. Before referral, Chest X‐Ray did not show additional lesions, cardiac function was stable, and no bacterial infection was proved. At arrival, the patient was stable on ECMO and mechanical ventilation. He underwent systematic nasal swab for SARS‐Cov2 PCR. After immunosuppressive treatment administration, the patient developed severe vasoplegic shock with bilateral lung consolidations (Figure 1) and 40.5°C temperature. SARS‐Cov2 PCR returned positive. The patient died few hours after the onset of the vasoplegic shock and could not be transplanted. The donor lungs were used for a second recipient tested negative for SARS Cov2 with good result despite longer cold ischemic time.

FIGURE 1

Sequential chest X‐Ray pictures with clinical correlation and timeline showing Idiopathic fibrosis patient history from high‐emergency double lung transplantation listing to Covid‐19 septic shock preventing him from the transplant procedure. All infectious exam but SARS‐Cov2 PCR were negative. Bilateral lung complete consolidation was found at the time of septic shock

Our case demonstrated the severity of COVID‐19 clinical worsening in Phase I disease when nasal swab PCR is positive. It seems mandatory to benefit from recipient SARS Cov2 PCR results as close as possible to acceptance of donor lungs for transplantation. Considering the time needed to run SARS‐Cov2 test, improved transplant logistic management, including ex vivo lung perfusion, simultaneous recipients call, rapid SARS‐Cov2 testing pathway, or pooling recipients between LTx centers will be undoubtly useful during COVID‐19 period. For our deteriorating patient, repeated routine testing would have been a solution to make a prompter diagnosis and better adapt medical management. Obtaining lower respiratory tract specimens such as tracheal aspirates in line with infection control precautions should be considered for intubated patients. Additionally, one should emphasize that COVID‐19 symptoms may have overlapped fibrosis worsening symptoms and delayed COVID‐19 diagnosis. Chest CT would have been an additional valuable diagnostic tool provided baseline images are available. Indeed, it may be challenging to differentiate lung disease from COVID‐19‐induced lesions. It is likely that our patient may have contracted the disease during his hospital stay. Asymptomatic SARS‐Cov2 carriers may be a source of virus spreading among health workers and patients. Maintaining containment, developing solutions to monitor COVID‐19 contacts, and routine screening are questions that should be discussed and regularly reassessed for listed outpatients. At least, we showed that solidarity between LTx programs was feasible and effective.

DISCLOSURES

None.

AUTHORS CONTRIBUTION

OM and AV conceived of the presented idea. OM wrote the study. FL, LF, HM, VB, DB, LW, and GD collected data for the manuscript. EF and AV supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.