# Restrictive Allograft Syndrome After COVID-19 Pneumonia: A Case Report

## TL;DR

A lung transplant patient developed restrictive allograft syndrome after contracting COVID-19 pneumonia, highlighting the severe risks for transplant recipients.

## Contribution

This case report highlights the rare but severe progression of restrictive allograft syndrome following COVID-19 in a lung transplant patient.

## Key findings

- A lung transplant recipient developed RAS after a COVID-19 infection.
- Steroid and antimicrobial therapies failed to prevent respiratory failure and death.
- Unusual clinical progression and imaging features were observed in this case.

## Abstract

Chronic lung allograft dysfunction (CLAD) continues to be the leading cause of death in the long term after lung transplantation (LTx). CLAD has the following two main subtypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). BOS features obstructive lung dysfunction, while RAS features restrictive lung dysfunction. Overall, RAS has a worse prognosis. The pathophysiology of CLAD is not fully understood; however, pulmonary infections can trigger CLAD, including coronavirus disease 2019 (COVID-19) pneumonia. Here, we describe a case of a 55-year-old female who received LTx about seven years ago and developed RAS after COVID-19 pneumonia. RAS was ultimately diagnosed based on the clinical course and imaging findings. Steroid pulse therapy and empirical antimicrobial therapy were initiated, but respiratory failure progressed, and the patient died 139 days after COVID-19 diagnosis, and 83 days after dyspnea progression. Clinicians should be aware of unusual stair-step clinical courses and imaging features in a given setting of pulmonary infection including COVID-19 to suspect CLAD in lung transplant patients.