MJA 222 (4) ▪ 3 March 2025 179 Medical education Lessons from practice Putting international practice into action: the first case of lung transplantation for COVID-19 in Victoria, Australia Clinical record A 61-year-old previously healthy man presented to hospital with acute type 1 respiratory failure after five days of coryzal symptoms and a positive coronavirus disease 2019 (COVID-19) rapid antigen test. Within 24 hours, the patient became progressively hypoxic, was rapidly intubated and transferred to Alfred Health in December 2022, a tier one Victorian extracorporeal membrane oxygenation (ECMO) service site, for veno-venous ECMO (Avalon Elite bi-caval dual lumen catheter). The patient was born in Chile and migrated to Australia at 5 years of age. His medical history was significant for mild asthma. The patient was a distant ex-smoker with a less than five pack-year smoking history. At the time of admission, he had received three COVID-19 vaccines (Comirnaty Original; Pfizer–BioNTech). The patient was treated with broad-spectrum antibiotics, antifungals and COVID-19-specific therapies, including baricitinib, remdesivir and dexamethasone. Initial COVID polymerase chain reaction (PCR) analysis identified the Omicron variant with a cycle threshold value of 29.8. In accordance with hospital guidelines, the patient was cleared of isolation precautions on Day 20 with a cycle threshold value of 30.7. Multiple complications occurred during hospitalisation, including deep venous thrombosis, ventilator-associated pneumonia, Pseudomonas aeruginosa bacteraemia, pancreatitis, cytomegalovirus viraemia and localised herpes simplex virus type 1 infection. A failed attempt at de-cannulation occurred two months after presentation, where the patient required re-cannulation within 48 hours due to respiratory distress. The patient remained awake on ECMO and participated in treatment decision discussions and rehabilitation. Lung transplantation assessment and waitlisting occurred four months after the patient started ECMO. Transplantation was delayed due to human leukocyte antigen (HLA) sensitisation following multiple platelet transfusions for bleeding after endoscopic retrograde cholangiopancreatography for investigation of pancreatitis. An HLA single antigen bead Luminex test was positive for 53 Class I HLA antibodies with a peak mean fluorescence intensity of 24 000. After three months, the test was repeated and results had improved to 33 Class I HLA antibodies with a peak mean fluorescence intensity of 15 072. Due to the patient’s Chilean heritage, he was tested for Chagas disease (nucleic acid test) and returned a positive result. However, the result was negative on blood smear, indicating a chronic-phase infection. A computed tomography scan was performed at this point and showed evidence of COVID-related pulmonary fibrosis (Box, A). The patient underwent bilateral sequential lung transplantation in June 2023, six months after admission. ECMO de-cannulation occurred the day after transplantation. He was discharged home 20 days post-transplantation with no oxygen requirement. At follow-up six months post-transplantation, the patient was functionally independent with clear lung fields on imaging (Box, B) and normal spirometry. Given the risk of reactivation of Chagas disease post- transplantation, monitoring with clinical and blood film surveillance was performed up until 100 weeks post-transplant. As of November 2024, there has not been reactivation of Chagas disease or allograft dysfunction and the patient continues a routine post-transplant immunosuppression regimen of prednisolone, tacrolimus and mycophenolate. Discussion This is the first reported case of lung transplantation as curative treatment for irreversible COVID-19 lung injury in Australia. Although lung transplantation for COVID-19 has been increasingly practised internationally, this indication is not well established in Australia. 1,2 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections continue to result in patients requiring prolonged ventilation for acute respiratory distress syndrome (ARDS) and pulmonary fibrosis. 3 In addition to the International Society for Heart and Lung Transplantation 2021 consensus document for the selection of lung transplant candidates, 4 an international case series suggested that potential lung transplant candidates with COVID-19 ARDS require two negative COVID-19 PCR results at least 24 hours apart and at least four to six weeks with no signs of recovery despite optimal medical therapy. 5 Recovery was defined by improvement in lung compliance, radiography and gas exchange. As seen in the patient (Box, A), post-acute COVID-19 pneumonia can progress to fibrotic lung disease with traction bronchiectasis, interlobular septal thickening, and ground glass with reticulation. 6 Short term outcomes of COVID-19 lung transplantation appear promising. Studies have found that lung transplantation for COVID-19 has acceptable one-year outcomes and no significant difference in survival outcomes compared with non-COVID-19 lung transplantation. 7,8 These studies also showed that ECMO treatment pre-transplant resulted in adequate functional status. As experienced with the patient, 1 Alfred Health, Melbourne, VIC. 2 Monash University, Melbourne, VIC. 3 Royal Melbourne Hospital, Melbourne, VIC. me.wong@alfred. org.au doi: 10.5694/mja2.52597 Melanie Wong 1 Bradley Gardiner 1 Rob Stirling 1,2 Golsa Adabi 1 Brooke Riley 1 Jyotika D Prasad 1,3 Gregory I Snell 1,2