LAUSR

Dear Editor, Reactivation and reinfection of COVID-19 is a rare and threatening complication with relevance for organ transplantation.1–4 We have recently observed a reinfection documented by severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) reverse transcriptasepolymerase chain reaction (RT-PCR) following a previous two negative RT-PCR tests and clinical convalescence in a kidney transplant recipient (KTR) which resulted inmortality (Figure 1). A 49-year-old gentleman with blood group O was waitlisted for kidney transplantation and received a deceased donor kidney transplant at our center in Ahmedabad, in June, 2020. He was hypertensive but non-obese and non-diabetic. The surgery was uncomplicated, and he received Thymoglobulin (1.5 mg/kg single dose). He had been diagnosed with an acute cellular and antibody-mediated rejection in first month after his transplant for which he had been treated with steroids, thymoglobulin, plasmapheresis, and intravenous immunoglobulin. His baseline serum creatinine was 2 mg/dl posttransplant on prednisolone, mycophenolate, and tacrolimus. On day 70 after his transplant, he was admitted for 7 days with mild COVID-19 (fever and cough), bilateral peripheral ground opacities on chest CT scan and positive SARS-CoV2 RT-PCR. He was discharged with supportive care without complications. He was doing well after discharge. His immunosuppression had been adjusted during his hospital stay and restored to his baseline regime by day 21 day after discharge with two negative RT-PCR tests. After he had been at home for 52 days, he was re-admitted with complaints of fever and cough in absence of any new COVID-19 exposure. At this second admission, he tested again positive for SARS-CoV2 RT-PCR, and his illness progressed from mild to severe COVID-19 in his 10-day hospital course, during which he also developed bacterial/fungal super-infections. Mycophenolate /tacrolimus was stopped and he was treated with oxygen, anticoagulation, convalescent plasma, steroids, and remdesivir. Unfortunately, he deteriorated and died on post-transplant day 147. The major differences in laboratory parameters between the first COVID-19 episode and second COVID-19 episode were his elevated red cells, an augmented neutrophil lymphocyte ratio, lower total leucocyte count, elevated Creactive protein, lactate dehydrogenase, D-dimers, and procalcitonin. The low (.6%) incidence in our center (1/157) should be cautiously interpreted, as many possible asymptomatic or mild severity reactivationsmayhavebeenunrecorded. To thebest of our knowledge, we report the first case of fatal outcome subsequent to reoccurring