A case of severe COVID‐19 despite full vaccination with mRNA‐1273 SARS‐CoV‐2 vaccine (Moderna) in a kidney transplant recipient

Abstract

To The Editor, Despite growing evidence indicating that solid organ transplant (SOT) recipients often have a low humoral response to mRNA-based coronavirus disease 2019 (COVID-19) vaccines, the reports of severe COVID-19 after vaccination among immunocompromised subjects are few.1 We identified a kidney transplant recipient (KTR) unable to mount an adequate immune response after two doses of mRNA1273 vaccine (Moderna), and who subsequently developed severe COVID-19. A 73-year-old Asian American male presented to our emergency department (ED) in New York on May 29, 2021, with decreased oral intake, nausea, lethargy, and progressive shortness of breath and cough for two weeks. He had a medical history significant for receiving a deceased donor renal allograft on February 10, 2020, insulindependent diabetes mellitus with a hemoglobin A1c level of 8.4%, and hypertension. His maintenance immunosuppressive therapy was prednisone 5 mg daily, mycophenolate mofetil (MMF) 500 mg twice daily and tacrolimus extended-release tablet 16 mg daily. He completed the two-dose series of mRNA-1273 severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) vaccines (Moderna) onFebruary11, 2021. On examination, the patient appeared to be tachypneic. His vital signs revealed temperature 36.9C, blood pressure 97/55mmHg, pulse 100 beats per minute, respiratory rate 35 breaths per minute, the oxygen saturation 92% while breathing ambient air. He was started on supplemental oxygen, delivered by nasal cannula at 2 L/min, which improved his oxygen saturation values to 94%–99%. His nasopharyngeal swab tested positive for SARS-CoV-2 by real-time reversetranscriptase–polymerase-chain-reaction (rRT-PCR) assay. Admission laboratory tests noted leukocytosis (white blood cell count 11.74 k/μl, reference range: 3.80–10.50 k/μl), and lymphopenia (absolute lymphocyte count 0.11 k/μl, reference range: 1.00–3.30 k/μl). Recent blood work from April 2, 2021 (two months prior to admission) showed a white blood cell count of 5.62 k/μl and an absolute lymphocyte count of 1.01 k/μl. Antibody tests against the SARS-CoV-2 nucleocapsid and receptor-binding domain (RBD) of the spike protein using the antiSARS-CoV-2 S enzyme immunoassay (Roche Elecsys) were both negative on May 31, 2021. The anti-nucleocapsid total antibody cutoff index (COI) in this patient was 0.14 (COI ≤ 0.99 was determined negative by the manufacturer) while the anti-spike RBD total antibody level was 0.40 U/ml (≤ 0.79 U/ml was determined negative). The initial chest computed tomography scan (Figure1) showedextensivebilateral F IGURE 1 The chest computed tomography scan showed extensive bilateral patchy interstitial and nodular ground-glass opacities, consistent with the findings of coronavirus disease 2019 (COVID-19)