Post-acute coronavirus disease 2019 (COVID 19) syndrome: HLH and cholangiopathy in a lung transplant recipient

• Published in: Clinical infection in practice 2022-07, Vol.15, p.100144-100144, Article 100144
• Main Authors: Roda, Silvia, Ricciardi, Alessandra, Maria Di Matteo, Angela, Zecca, Marco, Morbini, Patrizia, Vecchia, Marco, Chiara Pieri, Teresa, Giordani, Paola, Tavano, Angelo, Bruno, Raffaele
• Format: Article
• Language: English
• Subjects: Case Reports and Series; Haemophagocytic lymphohistocytosis; Post COVID-19 Cholangiopathy; Post Covid19 syndrome; Sars-CoV2
• ISSN: 2590-1702; 2590-1702
• DOI: 10.1016/j.clinpr.2022.100144

•In COVID19-associated respiratory failure, lung transplantation might be an option;•Sars-CoV2 infection was recognized as a cause of HLH in severe COVID19 cases;•Post-Covid cholangiopathy is described as a new clinical entity;•The treatments for HLH can increase the risk of infection of transplant recipients. Sars-CoV2 can cause severe pneumonia and acute respiratory distress syndrome (ARDS). In COVID-19-associated respiratory failure, lung transplantation might be an option (Bharat A). A previously healthy 63-year-old man with a nasopharyngeal swab positive for SarsCoV2 and radiological evidence of interstitial lung consolidations developed acute respiratory distress that required intubation and veno-venous extracorporeal membrane oxygenation support (VV ECMO). Because of no recovery of his lung function, he underwent a bilateral lung transplant. ICU stay was complicated by several episodes of bacterial superinfections and an increase of liver function tests (LFTs). Afterward, he faced a progressive clinical worsening associated to severe anemia, further rise of indices of cholestasis, hypertriglyceridemia and hyperferritinemia. Bone marrow smear showed a picture compatible with haemophagocytic lymphohistocytosis (HLH) and first and second line therapy were started. In addition, a transjugular hepatic biopsy was performed with histopathological evidence of portal and periportal fibrosis, compatible with Covid 19-related cholangiopathy. During the hospital stay, he developed several MDR opportunistic infections. The patient died few months later from multiorgan failure secondary to septic shock. A post-mortem confirmed a diagnosis of cholangiopathy, and medullary erythro-haemophagocytosis. Post Covid19 syndrome is a clinical entity that includes novel and old sequelae following recovery from Sars-CoV2 infections. Early identification of these diseases is crucial for adequate management and might influence the long term prognosis of these patients.