Department of Anaesthesia and Intensive Care, AOR San Carlo, S...

To the Editor We read with interest the article of Guillen et al 1 Here the authors described the management of a kidney transplanted patient infected by SARS CoV 2 that causes novel Coronavirus disease 2019 COVID 19 The authors stated that immunosuppressed patients might present with atypical clinical manifestation fever diarrhea fatigue without respiratory symptoms Also Li and colleagues2 reported SARS CoV 2 infection in two solid organ transplanted patients The two heart transplanted patients presented with variable severity of COVID 19 one mild and another with more severe manifestations requiring a prolonged hospitalization however both survived the event It could be possible that the activation of the immune system is responsible for the damage caused by SARS CoV 2 The activation of the immune system especially T cells represents a landmark of histological picture of lung injury related to COVID 19 Xu et al3 investigated the pathological characteristics of COVID 19 by human postmortem biopsies They found that histological picture of lung injury related to COVID 19 is similar to Acute Respiratory Distress Syndrome diffuse alveolar damage cellular fibromyxoid exudates desquamation of pneumocytes and hyaline membranes Also they analyzed the characteristics of peripheral CD4 and CD8 T cells They found a hyperactivated status with an increased concentration of highly proinflammatory CCR6 Th17 in CD4 T cells The authors concluded that overactivation of T cells accounts for in part the severe immune injury Although immunosuppressed solid organ transplanted patients could be more susceptible to SARS CoV 2 infection with severe clinical manifestations the anti inflammatory effects of immunosuppression could diminish the clinical expression of disease 4 Tacrolimus FK506 and cyclosporine Cyclosporin A CsA the most commonly used drugs for maintenance immunosuppression following solid organ transplantation reduce the production of interleukin 2 IL 2 a regulator of proliferation survival and maturation for all T cell Furthermore FK506 and mycophenolic acid inhibit interleukin 17 IL 17 production with a stronger inhibitory effect on Th17 5 If clinical manifestation and lung injury of COVID 19 are in part mediated by overactivation of T cells immune response data reported in the literature suggests that clinical conditions associated with impairment in T cell response like immunosuppression in solid organ transplanted patients could alter the clinical course and reduced the rate and severity of lung injury Although transplanted patients could be more susceptible to SARS CoV 2 infection with atypical manifestations the chronic use of immunosuppressive drugs could represent a protective factor for the serious clinical complication of the disease This hypothesis could also explain why patients with lymphopenia are those with the worst outcomes Lymphopenia could be caused by lung sequestration of hyperactivated T cell and immunodepression drug related could limit this effect Actually except for the case reports mentioned above we found no data about the incidence and outcome of COVID 19 in this cluster of patients Furthermore immunosuppressive drugs could be a valid therapeutic choice reducing the activity of the T cell immune system and preventing organ injury

Department of Anaesthesia and Intensive Care, AOR San Carlo, San Carlo Hospital, Potenza, Italy

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Immunosuppression drug‐related and clinical manifestation of Coronavirus disease 2019: A therapeutical hypothesis