A kidney transplant recipient with nausea, vomiting, and diarrhea after a recent COVID‐19 exposure

Abstract

Inevitably, physician thought processes may be skewed toward this diagnosis. [...]other causes of illness may be overlooked, resulting in potentially harmful delays in diagnosis and targeted treatment. Editors Sandy Feng discloses stock ownership or equity in Abbott, Amgen, Charles River Labs, Eli Lily, Glaxo‐Smith Klein, Hospira, Johnson and Johnson, Express Scripts, Medco, Merck, Pfizer, and Stryker; and research support from Cumberland, Novartis, and Quark. Six days prior, while asymptomatic, the patient had tested negative for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by polymerase chain reaction (PCR) in a nasopharyngeal specimen.

American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME)

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal‐based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace.

This month’s feature article is titled: “A kidney transplant recipient with nausea, vomiting, and diarrhea after a recent COVID‐19 exposure.”

Accreditation and Designation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of John Wiley & Sons, Inc., the American Society of Transplant Surgeons, and the American Society of Transplantation. John Wiley & Sons, Inc. is accredited by the ACCME to provide continuing medical education for physicians, and fulfills the requirements for the American Board of Surgery (ABS) for Maintenance of Certification (MOC).

John Wiley & Sons, Inc. designates this journal‐based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Need

The clinical presentation of any infection in organ transplant (OT) recipients may be atypical, and the importance of maintaining a broad differential diagnosis is key. Timely diagnosis and appropriate management of OT recipients with gastrointestinal symptoms and pneumonia can be impeded by common cognitive biases, especially in the setting of a global pandemic.

Purpose of Activity

This activity was designed to improve patient outcomes by increasing physician awareness of unusual pathogens causing life‐threatening pneumonia that can mimic coronavirus 2019 (COVID‐19) amid the ongoing pandemic.

Identification of Practice Gap

The diversity of symptoms associated with COVID‐19 complicates all triage, diagnostic workup, and empiric treatment approaches to patients presenting with an acute illness. Inevitably, physician thought processes may be skewed toward this diagnosis. Therefore, other causes of illness may be overlooked, resulting in potentially harmful delays in diagnosis and targeted treatment. This activity illustrates the diagnostic approach to an OT recipient presenting with gastrointestinal symptoms and radiographic evidence of pneumonia in the setting of the ongoing COVID‐19 pandemic.

Learning Objectives

Upon completion of this educational activity, participants will be able to:

• Compare the typical presentation of COVID‐19 to that of the disease in question.
• Critically evaluate, diagnose, and recommend treatment for OT recipients with gastrointestinal symptoms and pneumonia during the COVID‐19 pandemic.
• Identify common biases in diagnostic medical thinking.

Target Audience

This activity was designed to meet the educational needs of frontline healthcare providers working with organ transplant recipients.

Disclosures

No commercial support has been accepted related to the development or publication of this activity. John Wiley & Sons, Inc. has reviewed all disclosures and resolved or managed all identified conflict of interest, as applicable.

Editor‐in‐Chief

Allan D. Kirk has no relevant financial relationships to disclose.

Editors

Sandy Feng discloses stock ownership or equity in Abbott, Amgen, Charles River Labs, Eli Lily, Glaxo‐Smith Klein, Hospira, Johnson and Johnson, Express Scripts, Medco, Merck, Pfizer, and Stryker; and research support from Cumberland, Novartis, and Quark.

Matthew H. Levine discloses research support from Pfizer.

CME Manager, ASTS

Ellie Proffitt has no relevant financial relationships to disclose.

Authors

Alexis Hope Lerner, Liqi Shu, Ralph Rogers, and Dimitrios Farmakiotis have no relevant financial relationships to disclose.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Instructions on Receiving CME Credit

This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for 12 months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional 12 months.

Physicians must correctly answer 75% or more of the posttest items to claim MOC credit.

Follow these steps to participate, answer the questions and claim your CME credit:

• Log on to https://www.wileyhealthlearning.com/ajt
• Read the learning objectives, target audience, and activity disclosures.
• Read the article in print or online format.
• Reflect on the article.
• Access the CME Exam, and choose the best answer to each question.
• Complete the required evaluation and print your CME certificate.

A 57‐year‐old male with history of deceased‐donor kidney transplant 3 years ago presented to the hospital with 3 days of nausea, vomiting, and diarrhea. His immunosuppressive regimen was mycophenolate, tacrolimus, and prednisone. The patient’s roommate had been hospitalized with COVID‐19 20 days prior but had since returned home. Six days prior, while asymptomatic, the patient had tested negative for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by polymerase chain reaction (PCR) in a nasopharyngeal specimen.

He endorsed chills but denied cough, dyspnea, dysgeusia, myalgia, headache, or history of travel. He had a fever of 103.5°F and tachycardia to 110 but no hypoxia. He did not appear to be in significant distress. He had bibasilar crackles on lung exam and a normal abdominal exam.

Laboratory testing revealed leukocytosis (12.6/μL with 87% neutrophils), lymphopenia (0.8/μL), thrombocytopenia (122/μL), hyponatremia (127 mEq/L), and a mildly elevated creatinine (1.87 mg/dL, baseline: 1.3‐1.5 mg/dL). Chest radiograph (Figure 1) and computed tomography (CT) (Figure 2) showed a dense right middle lobe pneumonia. Repeat SARS‐CoV‐2 PCR, respiratory pathogen panel (both in a nasopharyngeal specimen), and Clostridium difficile toxin PCR in the stool were all negative. He was admitted to the inpatient transplant service for further care.

[Image Omitted. See PDF.] [Image Omitted. See PDF.]

1 QUESTIONS

Which of the following is most likely responsible for this patient’s symptoms, laboratory results, and imaging findings?

An intracellular bacterium

A mold

A parasite

A virus

A yeast

Which of the following tests should be the preferred next step towards diagnosis?

Pathogen‐specific antibodies in the serum

PCR in an oropharyngeal specimen

Serum β‐D‐glucan

Serum galactomannan

Urinary antigen

Which of the following is appropriate treatment for this infection?

Azithromycin

Hydroxychloroquine

Remdesivir

Voriconazole

Azithromycin and hydroxychloroquine

Which of the following cognitive biases likely affected the initial diagnostic approach to this case?

Availability bias

Dunning‐Kruger effect

Gambler’s fallacy

Blind obedience

All the above

To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt