SARS-CoV-2 evolution in a LuTX patient

A 48-year-old patient underwent lung transplantation because of severe COVID-19 aggravating systemic scleroderma-associated ILD despite still detectable SARS-CoV-2. Shortly after transplantation the graft was re-infected leading to virus persistence for more than four months. The virus differently evolved in the recipient and in the donor graft, adapted to monoclonal antibodies and hypermutated upon Molnupiravir treatment. Non-synchronized viral clearance in the upper and lower respiratory tract was likely attributed to HLA mismatching in the transplanted lung. This case demonstrates the feasibility of lung transplantation even without complete viral clearance. At the same time, however, it highlights the importance of recipient versus transplanted immune cells in combating respiratory infections within HLA-divergent immune environment in transplanted lungs advising caution in this vulnerable standard clinical practice.