Table 1.
Patient characteristics at time of COVID-19 and PCP co-diagnosis and subsequent treatment.
| Case 1 | Case 2 | |
|---|---|---|
| Age (years) | 28 | 51 |
| Indication for OLT | Decompensated AIH cirrhosis | Re-do OLT for HAT, initial OLT for PSC |
| Co-morbidities | T1DM, IgA deficiency, HRS-AKI at time of OLT requiring CVVHDF | CKD, UC (pan-proctocolectomy and ileostomy) |
| Time post OLT | 1 month | 8 years |
| COVID-19 vaccination | No | No |
| PCP prophylaxis | No | No |
| Immunosuppression at diagnosis | Basiliximab induction, tacrolimus (trough levels of 6–8μg/L), prednisolone (10 mg/day) | Tacrolimus (trough levels of 2–5μg/L), MMF (750 mg BD) |
| COVID-19 diagnosis | Positive nasopharyngeal swab PCR | Positive nasopharyngeal swab PCR |
| PCP diagnosis | Positive BAL PCR | Positive BAL PCR |
| CT thorax findings | Multifocal peripheral ground glass changes | Multifocal peripheral ground glass changes |
| BDG level (pg/ml) | 266 | 227 |
| WCC (x 109) | 13.03 | 4.71 |
| Lymphocyte count (x 109) | 0.36 | 0.39 |
| CRP (mg/L) | 32 | 96 |
| LDH (IU/L) | 495 | – |
| COVID-19 treatment | Dexamethasone (6 mg/day) escalated to methylprednisolone (1.5 mg/kg/day) plus remdesivir (200 mg loading then 100 mg/day for 4 days) | Prednisolone (40 mg/day) |
| PCP treatment | TMP-SMX, switched to primaquine and clindamycin due to pancytopaenia and methylprednisolone (1.5 mg/kg/day) | TMP-SMX, switched to primaquine and clindamycin due to pancytopaenia plus prednisolone (40 mg/day) |
| Immunosuppression changes | Prednisolone held whilst on IV steroids, low normal trough tacrolimus levels (5–7μg/L) | MMF held |
| ICU-specific treatment | Intubation and ventilation, V-V ECMO for 29 days, CVVHDF | Intubation and ventilation for 3 days, CVVHDF |
| 3-month outcome | Remains in ICU | Remains in ICU |
Abbreviations: AIH, autoimmune hepatitis; BAL, bronchoalveolar lavage; BD, twice daily; BDG, beta-D glucan; CRP, C-reactive protein; CKD, chronic kidney disease; COVID 19, coronavirus disease 19; CT, computed tomography; CVVHDF, continuous veno-venous haemodiafiltration; HAT, hepatic artery thrombus; HRS-AKI, hepatorenal syndrome acute kidney injury; ICU, intensive care unit; IgA, immunoglobulin A; IV, intravenous; LDH, lactate dehydrogenase; MMF, mycophenolate mofetil; OLT, orthotopic liver transplantation; PCP, pneumocystis pneumonia; PCR, polymerase chain reaction; PSC, primary sclerosing cholangitis; T1DM, type 1 diabetes mellitus; TMP-SMX, trimethoprim-sulfamethoxazole; UC, ulcerative colitis; VV-ECMO, veno-venous extracorporeal membrane oxygenation; WCC, white cell count.