Sampling
Out of 380 liver transplant patients, 265 patients participated in this study. (Fig. 1) According to the results of the investigation, 200 patients had no symptoms of viral infection. Sixty patients were suspected of having COVID-19 and five of them had a definite diagnosis of COVID-19 disease. Four of the infected patients were hospitalized at Imam Reza hospital and one of them was cared at home. The most common symptoms of COVID-19 in these patients were headache, anorexia, myalgia, fatigue, diarrhea, vomiting, and cough. The demographic characteristics and clinical courses of seven patients with COVID-19 are presented at Table 1 &2.
Case presentation
Seven patients out of 265 participants were identified with COVID-19. The majority of the patients were men with a median age of 64 (44–74) years. All of the patients were Muslim, Azeri-Turkish, married, and resident at Tabriz.
All patients underwent liver transplantation following liver cirrhosis. The median time after liver transplantation was 60 months with a range of 30 to 156 months. Patient No. 4 had a history of kidney transplantation from 6 years ago, and a history of brain cancer with recent lung metastasis. Patients No. 1 and 2 had a history of hypertension from 10 years ago and Patients No. 6 also mentioned a history of ulcerative colitis from 8 years ago.
The median of diagnosis time was 7 (3–14) days for all patients. Two patients were initially diagnosed with a common cold due to runny nose, nasal congestion, and hoarseness, which in both cases, the disease was diagnosed late which the mean time of diagnosis of COVID-19 in these patients was 12 ± 8.2 days in comparison with other patients which was 7.57 ± 3.55 days.
All patients have been in quarantine since late February 2020 and have no history of hospitalization, referral to the clinic, or travel, and have not met anyone except first-degree relatives. Three patients (Patients No. 3, 5, and 6) had a history of colds among their children, and the mothers of patients No. 5, and 6 had COVID-19, that the mother of No. 5 died following a respiratory arrest and the mother of No. 6 recovered after seven days hospitalization. Other patients do not mention any contact with a suspected or infected person.
In patient No. 1, the onset of symptoms was a dry cough, followed by shortness of breath and fever. In patients 2 and 3, the initial symptoms were runny nose, hoarseness, and nasal congestion, which is followed by a sputum cough and dyspnea. For the patient NO.4, the onset of symptoms was a dry cough and myalgia, followed by chest pain, dyspnea, and a sputum cough. Patient No. 5 experienced a sputum cough followed by a dry cough. Patient No. 6 started with fever and chills, lethargy, anorexia, and myalgia, and ended with a dry cough and dyspnea. Finally, in patient NO. 7, the only symptom was fever.
Dyspnea has been observed in almost all patients and gastrointestinal symptoms have not been observed in any of the patients.
All patients were alert at the time of admission; however, all hospitalized patients with COVID- 19 had low level of SPO2. Patient No. 2 refused to accept hospitalization despite having respiratory symptoms like dyspnea, cough, and decrease in SPO2. He preferred to be at home quarantined under the supervision of an infectious disease specialist.
The results of physical examination are shown in Table 2. The chest CT scan was positive in all patients. Blood counts in most of the cases showed an increase in AST and ALT without leukopenia. The laboratory results are shown in Table 2.
The median of the length of in-hospital stay was 8.50 (1–22) days. The dead patients were first admitted to the general ward then were transferred to the ICU due to dyspnea and a drop in SPO2. One of the dead patients also had brain cancer with lung metastasis.
Hydroxychloroquine and azithromycin have been used for all patients along with immunosuppressant therapy without any changes in their dosage. All patients received immunosuppressive drugs with the same dosage as they used before COVID- 19 diagnosis. Of the 7 patients, 2 patients (28.5%) died and 5 patients (71.5%) recovered. After discharge, patients were required to stay at home quarantine for 14 days.