Lung Transplantation in a Recipient with Novel 2009 H1N1 Influenza: Lessons Learned

First lung transplant in Wuhan for a critical and elderly COVID-19 patient

Introduction

We report the case of a 65‐year‐old Coronavirus disease 2019 (COVID‐19) patient with pneumonia and subsequent end‐stage pulmonary failure who required 63 days of mechanical ventilation (MV) and 62 days of extracorporeal membrane oxygenation (ECMO).

Methods

On Day 45, a comprehensive interdisciplinary discussion on the best course of treatment resulted in the general consensus that his lungs would not recover. As such, he was evaluated and listed for a lung transplant.

Results

We performed a bilateral lung transplant, and the patient was weaned off ECMO and MV postoperatively. This is the first report of lung transplants in patients with COVID‐19 in Wuhan.

Conclusions

We suggest that a lung transplantation may be a viable treatment for patients with end‐stage pulmonary failure secondary to COVID‐19 in selected situations.

Organization of thoracic surgical services during the COVID pandemic

INTRODUCTION

COVID-19 presented an unprecedented challenge for healthcare workers and systems around the world. Healthcare systems have adapted differently in terms of pandemic planning of regular services, adopting infection control measures and prioritising essential hospital services in the context of a burgeoning COVID-19 patient load and inevitable surge.

METHODS

We performed a review on current evidence and share our practices at a teaching hospital in Singapore.

RESULTS

We outline principles and make recommendations for continuity of delivering essential thoracic surgical services during this current outbreak.

CONCLUSIONS

The maintenance and provision of thoracic surgery services in this context requires good preplanning and vigilance to infection control measures across all levels.

The impact of influenza A(H1N1)pdm09 infection on immunosuppressed patients

Before the advent of the influenza A(H1N1)pdm virus in 2009, the information available about the clinical manifestations and prognosis of influenza in immunosuppressed patients was scarce. With the 2009 pandemic, knowledge of the behavior, severity and importance of antiviral therapy for influenza A infection in immunocompromised hosts has increased considerably. The aim of the present manuscript is to review the main challenges of influenza in the most representative immunosuppressed populations such as solid organ transplant recipients, hematopoietic stem cell transplant recipients, patients with solid and hematological cancer and human immunodeficiency virus infected patients.

Update on viral infections in lung transplantation

PURPOSE OF REVIEW

Lung transplantation is an established therapeutic option for patients with severe respiratory insufficiency. Graft dysfunction or rejection depends on the orchestrated prevention of infection(s) and the level of immune suppression. More recent reports underlined the role and pathogenicity of cytomegalovirus (CMV) infection in lung transplant recipients and the double-edged sword of maintaining antiviral immune responses versus guided immune suppression to avoid graft rejection. We present data concerning the nature of the cellular response to Epstein-Barr virus (EBV) and CMV, the subsequent use of cellular therapy in antiviral treatment modalities and discuss the role of H1N1 infection and other viral infections in lung transplantation recipients.

RECENT FINDINGS

Patients after lung transplantation showed a similar susceptibility to H1N1 infections as compared to the local, healthy community. After initial recovery and oseltamivir treatment, lung transplantation patients developed bronchiolitis obliterans syndrome. The genetic background of lung transplant recipients, defined by polymorphism in immune molecules, contributes to increased risk of CMV disease; CMV induces local pro-inflammatory chemokines (CXCL10). Anti-CMV prophylaxis does not impact on anti-CMV-directed cellular immune responses, defined by IFNγ and TNFα production. Asymptomatic EBV carriers showed higher numbers of EBV-reactive T cells. High EBV load carriers showed T cells with immune-exhaustion markers and decreased IFNγ production. Anti-CMV-directed cellular therapy may aid to better manage CMV-associated complications after lung transplantation.

SUMMARY

Pharmacological immune suppression, the genetic makeup of the patient as well as concurrent viral infections impact on the successful outcome of lung transplantation and call for more detailed immune-guided diagnostics and therapy.