Immunosuppressants

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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 38-year-old man developed coronavirus disease 2019 (COVID-19) pneumonia and Plasmodium vivax (P. vivax) malaria during treatment with mycophenolate mofetil, prednisolone and tacrolimus for immunosuppression.

The man, who had undergone orthotopic liver transplant (LT) for cryptogenic liver disease seven years ago, had been receiving oral immunosuppression medications with tacrolimus, prednisolone, mycophenolate mofetil [dosages not stated] along with amlodipine and aspirin. He presented to emergency medical services with throat irritation, acute onset febrile illness, lethargy and loss of sense of smell since five days. On admission, he had a temperature of 102°F, heart rate of 110 /minute, non-invasive blood pressure of 130/90mm Hg, oxygen saturation of 93% on room air and respiratory rate of 22 breaths/minute. He was in mild respiratory distress. Subsequently, reverse transcriptase (RT)-PCR for SARS CoV-2 was positive via nasopharyngeal swab. CT of the chest showed patchy areas of ground glass opacities noted in left upper lobe and right lower lobe and his CT severity score was 3/25. Blood investigations showed elevated levels of serum bilirubin, D-dimer, C-reactive protein, ferritin levels, serum lactate dehydrogenase and serum creatinine. Electrocardiogram revealed sinus tachycardia and arterial blood gas analysis on room air showed mild hypoxemia. Based on these findings, a diagnosis of COVID-19 pneumonia associated with mycophenolate mofetil, prednisolone and tacrolimus was confirmed [durations of treatments to reaction onset not stated].

The man received supplemental oxygen along with off label therapy with IV ceftriaxone and dexamethasone. He also received unspecified low molecular weight heparin and remdesivir. His tacrolimus therapy was continued and mycophenolate mofetil was discontinued. But, he continued to have high grade fever with rigors and chills with increasing oxygen requirement. Serial haemogram showed falling trend in platelets counts and elevated inflammatory markers. Thereafter, haemogram and peripheral smear examination (thick and thin smear) revealed ring and schizhont forms of P.vivax that was confirmed by rapid malarial antigen test that was positive for P.vivax. Further, he received artesunate and his condition gradually improved. Serial blood investigations revealed normalising inflammatory markers, platelet counts, renal and liver function tests. He was discharged on primaquine. Home quarantine for one week and rehabilitation were suggested. After 4 weeks, at follow up, he was symptom free and clinically stable.