Methylprednisolone/mycophenolate-mofetil/tacrolimus

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 29-year-old man developed COVID-19 pneumonia while receiving immunosuppressive therapy with methylprednisolone, mycophenolate mofetil and tacrolimus [duration of treatment to reaction onset not stated].

The man presented to the clinic on 20 January 2020 with dry cough and fever (37.3°C) of 1 day (current presentation). He was the resident of a local community in Wuhan city, and had no travel history out of the city for 3 months prior to the presentation. In July 2010, he had undergone kidney transplantation. Since the transplantation, he had been maintained on immunosuppressive therapy with oral methylprednisolone 4mg every day, mycophenolate mofetil 500mg every 12 hours and tacrolimus 1−1.5mg every 12 hours (concentration remained: 4.0−5.0 ng/mL) [not all routes not stated]. Prior to the presentation, he was generally fit, and was regularly followed-up as an outpatient. During last follow-up examination on 16 January 2020, no signs of physical discomfort were noted. At the time of current presentation (on 20 January 2020), he was prescribed oseltamivir 75mg (off-label) twice a day and moxifloxacin for 6 days. However, his fever persisted (37.6°C−38.8°C), which was followed by the development of chest tightness, shortness of breath, cough, dyspnoea and breathlessness. CT scan performed on 26 January 2020, showed multiple patchy ground glass opacities and exudative lesion in both the lungs. Blood oxygen saturation fluctuated between 80−90%, and a decrease in lymphocyte count was observed. Based on the examinations, COVID-19 infection was suspected, and he was hospitalised. Real-time reverse transcriptase-PCR (RT-PCR) of the nasopharyngeal swab specimen for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. The diagnosis of COVID-19 pneumonia was confirmed.

The man was recommended to stop mycophenolate mofetil from 26 January 2020, and methylprednisolone and tacrolimus were maintained at the same dose. He received treatment with interferon-alpha-2b (off-label) inhalation 5.0 million units twice a day, ceftazidime and moxifloxacin. He also started taking Chinese medicine decoction (containing radix paeoniae alba, lily, rhizome atractylodis, roasted malt 30g, pericarpium citri reticulatae, ligusticum chuanxiong hort, dangshen, licorice, pogostemon cablin, officinal magnolia bark, forsythia, spina date seed, honey-fried licorice root, poria cocos, bran fried rhizoma atractylodis). According to the blood saturation of oxygen, the flow rate of oxygen therapy was adjusted. From 5 February 2020, his condition improved with a decrease in body temperature to 36.5°C and improved blood oxygen saturation, which remained around 95% when oxygen therapy was temporarily stopped for functional evaluation. His dyspnoea and breathlessness disappeared. However, he continued to experience slight dry cough. Hence, the same treatment was continued for another 8 days. On 13 February 2020, all COVID-related symptoms disappeared. Repeat CT scan demonstrated an absorption of shadows in both the lungs. His interferon-alpha-2b and antibiotics treatment was stopped, but he continued to take traditional Chinese medicine. Two consecutive RT-PCR tests for SARS-CoV-2 yielded negative results. On 23 February 2020, he was discharged. Thereafter, he had routine examinations, during which an increase in leukocyte and lymphocyte count was observed. Follow up examination (3 weeks after discharge), revealed no fever or other symptoms. His leukocyte count and classification were normal.

The man's treatment with mycophenolate mofetil was restarted, while methylprednisolone and tacrolimus doses remained unchanged.