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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">COVID-19 reinfections in immunocompromised patients are a challenge for scientific community&#46; Here we present the first case of a kidney transplant receipt with a lethal COVID-19 reinfection&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">He is a 60-year-old male&#44; with chronic kidney disease &#40;CKD&#41; due to focal and segmental glomeruloesclerosis that received his first kidney transplant 2004&#46; In treatment with prednisone and rapamycin since 2007 when we was diagnosed of a hepatocellular carcinoma&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In August 2020&#44; after a close contact to a COVID-19 family member&#44; he developed mild symptoms &#40;cough and low-grade fever&#41; and SARS-CoV-2 infection was confirmed by a positive nasopharyngeal real-time reverse transcription-polymerase chain reaction &#40;rRT-PCR&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The clinical course was favorable&#44; and he did not need further clinical assistance in that moment&#46; A confirmatory rRT-PCR was performed showing a negative result&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In December 2020 and January 2021&#44; he was admitted in the hospital due to two episodes of urinary tract infection caused by <span class="elsevierStyleItalic">Staphilococcus aureus</span> and <span class="elsevierStyleItalic">Serratia marcenses</span>&#46; In both hospitalizations&#44; rRT-PCR were repeated five times &#40;12th&#44; 30th December and 4th&#44; 9th&#44; 17th January 2021&#41; resulting negative in all of them&#46; A chest X-ray performed on 12th December 2020 showed very low intensity bilateral infiltrates&#46; In addition&#44; on 8th January 2021&#44; a chest-abdomen computed tomography scan demonstrated bilateral infiltrates in both hemithorax&#44; probably as a residual lesion of the SARS-CoV-2 previous infection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; After diuretic and antibiotic treatment&#44; chest X-ray improved significantly&#44; and the patient was discharge asymptomatic 20th January 2021&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; 28th January 2021&#44; the patient was again admitted due to respiratory fever and acute injury of the allograft function&#46; A chest X-ray showed bilateral infiltrates with unilateral pleural effusion&#46; A new rRT-PCR confirmed SARS-CoV-2 infection by the same viral genotype&#44; so immunosuppression was stopped&#44; and dexamethasone was started&#46; A thoracentesis of the pleural effusion demonstrated SARS-CoV-2 in the obtained sample&#46; Antibodies &#40;IgM and IgG&#41; for SARS-CoV2 resulted negative&#46; Although he was theoretically immunosuppressed&#44; lymphocyte populations were normal&#46; Despite established treatment including high flux oxygen&#44; the patient deceased on 5th February 2021&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Several doubts have emerged around reinfections in general population&#46; Technical errors in specimen collection or false negative results in rRT-PCR have been demonstrated in many patients driving to mistakes in COVID-19 reinfections&#46; In addition&#44; virus or non-active fragments of them can persist in sputum for weeks showing false positive results&#46; However&#44; the most part of the published reinfections have shown an asymptomatic course in the second positive rRT-PCR episode&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> This situation interestingly differs from our patient who presented a pauci-symptomatic course of COVID-19 infection with a lethal reinfection 5 months later&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our patient presented some confirmatory features of a COVID-19 reinfection&#46; First&#44; he had positive rRT-PCR concurring with a family member contact and some mild symptoms&#46; Despite this classical clinical picture&#44; and even using a highly specific rRT-PCR&#44; in some circumstances false positives can occur&#46; Second&#44; we confirmed negative rRT-PCR in several times&#44; but radiological images showed residual bilateral lesions suggestive of COVID-19 past infection&#46; Third&#44; he developed new symptoms and chest X-ray worsen significantly simultaneously&#46; In addition&#44; in the reinfection episode&#44; pleural effusion revealed the presence of SARS-COV-2 in the lungs&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Reasons for reinfection have not been widely studied&#44; in part because immune response to SARS-CoV-2 has not been yet addressed&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Probably&#44; immunosuppressive factors can contribute to limit viral clearance and to impair cellular and humoral immunity in COVID-19 as in other infections&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> The clinical course of our patient agrees with this hypothesis&#46; Although lymphocyte populations were normal at admission&#44; in our patient concurred the personal history of the active neoplasia and the immunosuppression due to kidney transplant&#46; Unfortunately&#44; data regarding humoral or cellular immunity was not available after the first episode&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">On this regard&#44; reinfections can raise some concerns about the COVID-19 vaccines efficacy in those populations with risk factors for attenuating humoral immunity&#46; In addition&#44; pivotal COVID-19 vaccines randomized clinical trials have systematically excluded CKD patients so there is an important lack of information about their efficacy in that population&#46; A very recent investigation letter has shown that a single dose of SARS-CoV2 mRNA vaccine generates a poor antispike antibody response&#44; situation than can explain a COVID-19 reinfection&#44; especially more than 4 months before the primoinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> On the other hand&#44; we must be cautious with those patients with prior episodes of COVID-19 who develop new symptoms and chest X-ray lesions and&#44; of course&#44; always recommend maintaining infection preventive measures&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; reinfections in kidney transplants are plausible and require paying attention to those patients who developed COVID-19 symptoms even if they have had a previous episode&#46;</p></span>"
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Letter to the Editor
COVID-19 reinfection in a kidney transplant recipient, time for rethinking?
Reinfección por COVID-19 en un paciente portador de trasplante renal, ¿tiempo para reflexionar?
Borja Quirogaa,
Autor para correspondencia
borjaqg@gmail.com

Corresponding author.
, Andrés Fernández Ramosa, Alicia Delgado Arroyob
a Nephrology Department, Hospital Universitario de La Princesa, Madrid, Spain
b Intensive Care Unit, Hospital Universitario de La Princesa, Madrid, Spain
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&#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The clinical course was favorable&#44; and he did not need further clinical assistance in that moment&#46; A confirmatory rRT-PCR was performed showing a negative result&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In December 2020 and January 2021&#44; he was admitted in the hospital due to two episodes of urinary tract infection caused by <span class="elsevierStyleItalic">Staphilococcus aureus</span> and <span class="elsevierStyleItalic">Serratia marcenses</span>&#46; In both hospitalizations&#44; rRT-PCR were repeated five times &#40;12th&#44; 30th December and 4th&#44; 9th&#44; 17th January 2021&#41; resulting negative in all of them&#46; A chest X-ray performed on 12th December 2020 showed very low intensity bilateral infiltrates&#46; In addition&#44; on 8th January 2021&#44; a chest-abdomen computed tomography scan demonstrated bilateral infiltrates in both hemithorax&#44; probably as a residual lesion of the SARS-CoV-2 previous infection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; After diuretic and antibiotic treatment&#44; chest X-ray improved significantly&#44; and the patient was discharge asymptomatic 20th January 2021&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; 28th January 2021&#44; the patient was again admitted due to respiratory fever and acute injury of the allograft function&#46; A chest X-ray showed bilateral infiltrates with unilateral pleural effusion&#46; A new rRT-PCR confirmed SARS-CoV-2 infection by the same viral genotype&#44; so immunosuppression was stopped&#44; and dexamethasone was started&#46; A thoracentesis of the pleural effusion demonstrated SARS-CoV-2 in the obtained sample&#46; Antibodies &#40;IgM and IgG&#41; for SARS-CoV2 resulted negative&#46; Although he was theoretically immunosuppressed&#44; lymphocyte populations were normal&#46; Despite established treatment including high flux oxygen&#44; the patient deceased on 5th February 2021&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Several doubts have emerged around reinfections in general population&#46; Technical errors in specimen collection or false negative results in rRT-PCR have been demonstrated in many patients driving to mistakes in COVID-19 reinfections&#46; In addition&#44; virus or non-active fragments of them can persist in sputum for weeks showing false positive results&#46; However&#44; the most part of the published reinfections have shown an asymptomatic course in the second positive rRT-PCR episode&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> This situation interestingly differs from our patient who presented a pauci-symptomatic course of COVID-19 infection with a lethal reinfection 5 months later&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our patient presented some confirmatory features of a COVID-19 reinfection&#46; First&#44; he had positive rRT-PCR concurring with a family member contact and some mild symptoms&#46; Despite this classical clinical picture&#44; and even using a highly specific rRT-PCR&#44; in some circumstances false positives can occur&#46; Second&#44; we confirmed negative rRT-PCR in several times&#44; but radiological images showed residual bilateral lesions suggestive of COVID-19 past infection&#46; Third&#44; he developed new symptoms and chest X-ray worsen significantly simultaneously&#46; In addition&#44; in the reinfection episode&#44; pleural effusion revealed the presence of SARS-COV-2 in the lungs&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Reasons for reinfection have not been widely studied&#44; in part because immune response to SARS-CoV-2 has not been yet addressed&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Probably&#44; immunosuppressive factors can contribute to limit viral clearance and to impair cellular and humoral immunity in COVID-19 as in other infections&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> The clinical course of our patient agrees with this hypothesis&#46; Although lymphocyte populations were normal at admission&#44; in our patient concurred the personal history of the active neoplasia and the immunosuppression due to kidney transplant&#46; Unfortunately&#44; data regarding humoral or cellular immunity was not available after the first episode&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">On this regard&#44; reinfections can raise some concerns about the COVID-19 vaccines efficacy in those populations with risk factors for attenuating humoral immunity&#46; In addition&#44; pivotal COVID-19 vaccines randomized clinical trials have systematically excluded CKD patients so there is an important lack of information about their efficacy in that population&#46; A very recent investigation letter has shown that a single dose of SARS-CoV2 mRNA vaccine generates a poor antispike antibody response&#44; situation than can explain a COVID-19 reinfection&#44; especially more than 4 months before the primoinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> On the other hand&#44; we must be cautious with those patients with prior episodes of COVID-19 who develop new symptoms and chest X-ray lesions and&#44; of course&#44; always recommend maintaining infection preventive measures&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; reinfections in kidney transplants are plausible and require paying attention to those patients who developed COVID-19 symptoms even if they have had a previous episode&#46;</p></span>"
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ISSN: 02116995
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