ARDS IN CYSTIC FIBROSIS PATIENT WITH DOUBLE LUNG TRANSPLANT SURVIVES SARS-COV-2

Modugula, Sujith; Adroja, Shubham; Lim, Joseph Michael; Daoud, Ansaam; Harris, Randall

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cystic fibrosis (CF) often leads to a double-lung transplant, making patients highly vulnerable to viral infections. For instance, the H1N1 influenza pandemic affected many people, with those who incurred it suffering significant morbidity. A recent study published in the Journal of Cystic Fibrosis has shown 40 confirmed cases of CF patients with SARS-CoV-2 worldwide up to April 2020. This is a unique case of a cystic fibrosis patient with ARDS with SARS-CoV-2 that required mechanical ventilation. CASE PRESENTATION: A 23-year-old Caucasian male with double-lung transplant due to cystic fibrosis, complicated by pancreatic insufficiency presented with acute dyspnea, cough, and fever. He was immunosuppressed due to tacrolimus, mycophenolate, and chronic prednisone use. His mycophenolate was held in the setting of presumed sepsis however his tacrolimus and prednisone were continued given the risk of rejection. Subsequently, his respiratory status rapidly declined prompting admission to the Intensive Care Unit for mechanical ventilation. Computed tomography of the chest endorsed worsening acute respiratory distress syndrome-like feature requiring high positive end-expiratory pressure [PEEP] settings. Labs revealed elevated d-dimer, CRP, interleukin-6 (IL-6) and clinical features consistent with cytokine storm. Recent literature suggested a possible role of tocilizumab, an anti-IL-6 antibody. He received 400mg of Tocilizumab, following which the patient drastically improved. ICU care was challenging because of potential pharmacologic variance and adynamic ileus in the setting of cystic fibrosis with sedation and paralytics. Patient was liberated after 5 days of mechanical ventilation. Interestingly, he remained SARS-COV-2 positive post discharge for several weeks afterward. DISCUSSION: This critically ill immunosuppressed patient, unusually, exhibited rapid recovery. From the 40 patients in the study from Journal of Cystic Fibrosis, there was no mortality reported and only one patient reported to require mechanical ventilation associated with SARS-CoV-2. Factors that may have influenced this patient's recovery and lower mortality is the prompt use of Tocilizumab and his young age. Tocilizumab is currently an experimental medication, noted to inhibit further clinical deterioration. CONCLUSION(S): Fortunately, this case did not have long term consequences, however, that may not be the norm. Many CF patients have double lung transplants and the long-term impact of SARS-CoV-2 amongst CF patients is not known. More research may be warranted for the long-term effects of CF patients with SARS-CoV-2. Reference #1: Rebecca Cosgriff, Susannah Ahern, Scott C. Bell, Keith Brownlee, Pierre-Regis Burgel, Cass Byrnes, Harriet Corvol, Stephanie Y. Cheng, Alexander Elbert, Albert Faro, Christopher H. Goss, Vincent Gulmans, Bruce C. Marshall, Edward McKone, Peter G. Middleton, Rasa Ruseckaite, Anne L. Stephenson, Siobhan B Carr, A multinational report to characterise SARS-CoV-2 infection in people with cystic fibrosis,Journal of Cystic Fibrosis,2020 Reference #2: Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24. Erratum in: Lancet. 2020 Jan 30. Reference #3: L. Viviani, B.M. Assael, E. Kerem ECFS (A) H1N1 study group. Impact of the A (H1N1) pandemic influenza (season 2009-2010) on patients with cystic fibrosis J Cyst Fibros, 10 (5) (2011), pp. 370-376, 10.1016/j.jcf.2011.06.004 Epub 2011 Jul 12. PMID: 21752728 DISCLOSURES: No relevant relationships by Shubham Adroja, source=Web Response No relevant relationships by Ansaam Daoud, source=Web Response No r levant relationships by Randall Harris, source=Web Response No relevant relationships by Joseph Michael Lim, source=Web Response No relevant relationships by Sujith Modugula, source=Web ResponseCopyright © 2020 American College of Chest Physicians