Mycophenolic-acid/prednisone/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 man in his early 50s developed COVID-19 pneumonia during immunosuppressive therapy with mycophenolic acid, prednisone and tacrolimus [routes, dosages, times to reaction onset and outcome not stated].

The man presented to the hospital with productive cough, fever, widespread myalgias, and escalating shortness of breath for last four days. He had a significant history of kidney transplantation for end-stage kidney disease caused by hypertension, followed by cellular graft rejection and persistent collapsing focal segmental glomerulosclerosis. Physical evaluation revealed that he had tachypnoea, a fever of 102.3F with an O ₂ saturation of 90% on a 100% non-rebreather, but otherwise normal. He had been receiving immunosuppressive therapy with prednisone, mycophenolic acid and tacrolimus along with numerous unspecified anti-hypertensive medications. He was therefore hospitalised, and was diagnosed with COVID-19 pneumonia. He was then transferred to the ICU due to laboured breathing, immunosuppressed status and multiple comorbidities.

The man was treated with meropenem along with high flow oxygen and awake proning. His unspecified anti-hypertensive treatments were stopped due to his normal blood pressure, but his immunosuppressive regimen was continued, with the exception of mycophenolic acid [mycophenolate], due to the risk of significant infection. He received high-titer convalescent plasma therapy on day 1 and tocilizumab on day 2. He was intubated on day 2 due to his deteriorating respiratory condition. His unspecified antibiotic regimens were changed to piperacillin-tazobactam and vancomycin, and eventually stopped on day 3, when he became afebrile. He developed bilateral deep venous thrombosis, and he received heparin on day 3. He was cannulated and started on veno-venous extracorporeal oxygenation due to deteriorating hypoxic respiratory failure despite full mechanical ventilation assistance on day 5. His oxygenation gradually improved and stabilised, which led to a tracheostomy on day 16 and extracorporeal oxygenation explantation on day 20. Subsequently, he developed fever and a septic infection caused by Proteus mirabilis pneumonia and Enterococcus bacteremia, and he was restarted on piperacillin/tazobactam and vancomycin on day 20. He experienced a septic shock and was initiated on unspecified vasopressors on day 21. His antibiotic therapy was reduced to ampicillin on day 21 and was maintained for 7 days. His septic shock resolved, and he was re-initiated on unspecified anti-hypertensives once his blood pressure stabilised. Periodic desaturations, anaemia, narrow and wide complex tachycardia and thrombocytopenia continued to exacerbate his condition [aetiology not stated]. He gradually improved sedation weaning and permitting ventilation. His dysphagia persisted during his rehabilitation. A percutaneous endoscopic gastrostomy tube was inserted on day 28 for nutritional status improvement. His nasopharyngeal swab SARS-CoV-2 RT-PCR test showed negative results on day 45. His condition improved, and he was moved to a step-down unit on day 49, and then discharged to a long-term care facility on day 64 requiring only ventilatory assistance at night. He died unexpectedly due to hypoxic respiratory failure caused by his COVID-19 pneumonia on day 94.