Abstract
Introduction Coinfection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza B at the time of lung transplantation is exceptionally rare and raises concern for early graft injury and impaired postoperative recovery. Understanding how viral load, inflammatory response, and pulmonary function evolve after transplant can help guide management in such complex cases. Case Description A 70-year-old woman with end-stage pulmonary fibrosis underwent bilateral lung transplantation with concomitant single-vessel coronary artery bypass grafting. Preoperative nasopharyngeal swabs were positive for SARS-CoV-2 and influenza B by PCR, with a high COVID-19 cycle threshold (Ct 40.7) and negative inflammatory markers. She was asymptomatic and completed a 5-day course of oseltamivir postoperatively with excellent graft function at discharge 10 days after transplant. On postoperative day (POD) 15, spirometry showed FVC 78% and FEV1 70% predicted. At POD 50, she developed mild symptomatic COVID-19 infection confirmed by PCR (Ct 20.4) and was treated with molnupiravir and a short prednisone course; mycophenolate was temporarily reduced. Chest CT demonstrated multifocal ground-glass opacities and small pleural effusions (Figure 1). Inflammatory markers including CRP, ferritin, D-dimer, and LDH were elevated, but oxygenation remained stable, and tocilizumab was not required. Over subsequent months, spirometry initially declined to FVC 61% and FEV1 61% at 6 months, then improved to FVC 82% and FEV1 83% at one year. She experienced no respiratory failure, acute rejection, or infection-related complications. Discussion This case demonstrates that asymptomatic coinfection with COVID-19 and influenza B at the time of lung transplantation is not necessarily prohibitive to successful outcomes. Viral burden, clinical symptoms, and imaging findings should guide decision-making rather than PCR positivity alone. Low viral load with absent systemic inflammation may permit safe transplantation when coupled with vigilant postoperative monitoring. Stepwise management including early antiviral therapy, temporary reduction in antimetabolite immunosuppression, and limited corticosteroid use can stabilize the clinical course without compromising graft function. At one year, this patient achieved excellent pulmonary recovery, underscoring the importance of individualized, multidisciplinary management in the setting of viral coinfection. This abstract is funded by: None