ABSTRACT Pneumocystis jirovecii (PJ) opportunistic infections occur in immunocompromised patients impacting significantly hospitalizations and mortality. Trimethoprim-sulfamethoxazole (TMP-SMX) is universally used as prophylaxis of Pneumocystis jirovecii pneumonia (PJP) and therefore, this infection is rare condition in solid organ transplant (SOT) recipients. We present a case of a 46-years-old male, who received an ABO-incompatible transplant with prior desensitization protocol with plasmapheresis, rituximab, and anti-CMV immunoglobulin. IgG anti-B title pre-desensitization was 1:128. The patient had 6 ABDR mismatches, without HLA antibodies, and the CDC crossmatch for T and B cells was negative. Both recipient and donor were CMV positive (D+/R+). The patient received induction immunosuppression with corticosteroids, basiliximab, calcineurin inhibitor, and mycophenolate mofetil. Immediate kidney function was verified, and three additional plasmapheresis sessions were performed. At discharge serum creatinine (sCr) was 1.38 mg/dL, but kidney function declined during the first 6 months (sCr 2.5 mg/dL). Urinalysis was unremarkable. A kidney biopsy was declined by the patient. Unit protocol maintained the prophylaxis for PJP and cytomegalovirus (CMV) infection with TMP-SMX and valganciclovir. The patient was admitted to the emergency department 20 months after the transplant with respiratory symptoms and was diagnosed with PJP. Bronchoalveolar lavage fluid was also positive for CMV. Intensive care unit (ICU) admission was necessary due to clinical deterioration, with subsequent good evolution without mechanical ventilation. At discharge, prophylaxis with TMP-SMX and valganciclovir was maintained for more than six months. Here we discuss the late onset of PJP, and the main risk factors related to severe infection. Transplant subgroups in which longer PJP prophylaxis could be beneficial and the indication to re-start PJP prophylaxis is still under discussion.

ABSTRACT Older to older living kidney transplantation is an acceptable alternative to avoid dialysis, improve quality of life and maintain favorable long-term outcomes of patients with end-stage kidney disease. However, the management of these patients is complex and the acceptance of older donors and recipients to kidney transplantation remains controversial. The older recipients usually have several comorbidities that may complicate the postoperative course and increase the risk of end-stage kidney disease. We present a clinical case of living kidney transplantation between an older donor and recipient, both over 70 years old, who evolved to a stage 3 chronic kidney disease, without proteinuria, hypertension, or other complications, three years after transplantation. Our case reinforces favorable outcomes in older living transplantation, both for recipient and donor, as has been demonstrated in several published studies.

Resumo Introdução: A Rede CUF em 18 de março, disponibilizou o Hospital CUF Infante Santo (HCIS) como hospital de referência para os doentes com COVID-19 na área da grande Lisboa. O internamento do doente não crítico (IDNC) ficou a cargo de uma equipa médica dedicada (EMD) constituída por médicos do Cluster Tejo, sob coordenação da Medicina Interna. Este estudo reporta as principais características demográficas e clínicas da população internada no IDNC. Material e métodos: Estudo retrospetivo analisando os doentes admitidos entre 27 de março e 7 de maio de 2020, no IDNC. Os critérios para diagnóstico de COVID-19 basearam-se na confirmação laboratorial e/ou critérios de diagnóstico imagiológicos. Excluíram-se da análise os doentes inicialmente suspeitos, mas cujo diagnóstico final encontrado foi outro. Clinicamente, o doente não crítico foi definido como tendo um Modified Early Warning Score (MEWS) entre 0-2. Os dados foram coletados do processo clínico eletrónico e da base de dados criada para seguimento destes doentes. Apresentam-se as características demográficas, clínicas, exames complementares, terapêutica e resultados. Resultados: Incluíram-se 44 doentes, média de idades 67 anos, 52,3% homens. Divididos em grupos de acordo com a apresentação, com pneumonia em 75%, os restantes com outra apresentação. Proveniência: domicílio 81,8%, residência sénior 11,4% e outro hospital 8%. Fatores de risco para doença mais grave foram: Idade > 65 anos, 56,8%, hipertensão arterial 59%, doença respiratória crónica 15,9%, obesidade 15,9%, neoplasia ativa 13,6%, diabetes 11,4%, cardiopatia isquémica 11,4%, insuficiência cardíaca 6,8%, imunossupressão 6,8%, com índice de comorbilidades de Charlson média de 3.6. Agravamento clínico significativo com necessidade de escalar cuidados em três doentes (6,8%), em dois (4,5%) com ventilação mecânica invasiva, adicionalmente registado um óbito (2,3%). Demora média de internamento 10 dias, três (6,8%) doentes foram transferidos para outro hospital e 40 (91%) tiveram alta. Discussão: A casuística apresentada representa o primeiro grupo de doentes não críticos internados com COVID-19 na Rede CUF da Região de Lisboa. Houve evolução e mortalidade intra-hospitalar abaixo do expectável para as características desta população, nomeadamente perante a presença de fatores de risco para doença mais grave e elevado índice de comorbilidades. Conclusão: A interpretação dos resultados obtidos fica condicionada ao pequeno tamanho da amostra e às incertezas ainda existentes nesta nova doença.

Abstract Introduction: On 18th March, CUF Group made the CUF Infante Santo Hospital (HCIS) available as the reference hospital for patients with COVID-19, in Lisbon area. The dedicated medical team (DMT) formed by doctors from the Tejo Cluster, under the coordination of Internal Medicine, was responsible for the non-critical patients’ hospitalization (NCPH). This study reports the main demographic and clinical features of the admitted population. Material and methods: Retrospective study that analysis the features of NCPH, between 27th March and 7th May 2020. The diagnosis criteria for COVID-19 were based on laboratorial confirmation and/or imaging criteria. The non-critical patient was defined as the patient that presented a Modified Early Warning Score (MEWS) between 0 and 2. Data was collected from patient’s electronic clinical files and from the database created for the follow-up of these specific patients. Demographic and clinical features, complementary exams, therapy and results are presented in this paper. Results: We included 44 patients in the study, the mean age was 67 years old, 52.3% were male. Patients were divided in groups according to the presence of Pneumonia (75%) or not (25%). Origin of the patients: home 81.8%, nursing home 11.4% and other hospital 8%. Distribution according to risk factors of severe disease was: Age >65 years old (56.8%), high blood pressure (59%), chronic respiratory disease (15.9%), obesity (15.9%), active cancer (13.6%), diabetes (11.4%), ischemic heart disease (11.4%), heart failure (6.8%), immunosuppression (6.8%), with a mean score of Charlson’s comorbidity index of 3.6. There was an increase on the severity of the clinical status of 3 patients (6.8%) requiring an escalation of the clinical care, leading to 2 (4.5%) patients requiring assisted ventilation and 1 death (2.3%). Mean length of stay was 10 days, 3 (6.8%) patients were transferred to another hospital and 40 (91%) were discharged. Discussion: The sample presented in this study, represents the first group of non-critical patients admitted with COVID-19 into CUF Health care units in Lisbon region. Taking into account the admitted population (namely risk factors for severe disease and an elevated comorbidity index), evolution and in-hospital mortality were better than expected. Conclusion: Interpretation of these results is conditioned by the small size of this sample and the existing uncertainties with this new disease.