*Purpose: Novel coronavirus infection has been rarely described in multi-organ transplantation. This case highlights the poor prognosis associated with cardiac involvement by SARS-Cov-2 in transplantation, despite resolution of respiratory infection.

*Methods: Case report from retrospective chart review.

*Results: The patient is a 48 year old woman with end stage lung and renal disease. In late 2019, the patient underwent a bilateral lung transplant and simultaneous kidney transplant. Postoperative period was noted for multiple readmissions for post-obstructive pneumonia. By early March 2020 she had made a good functional recovery. In late March the patient’s husband, who worked as a ride-share driver, developed fevers and cough but continued working. Four days later, the patient developed fevers and a productive cough. This is considered her first day of COVID-19 symptoms. Subsequent days will be referred to as ‘post-symptom days’ (PSD#). She presented on PSD#4 with a fever of 102.8 F. The patient’s COVID test was positive. During her five-day hospitalization, she remained afebrile, and she was weaned off oxygen. Echocardiogram was normal. She continued to do well clinically and was asymptomatic at discharge, with oxygen saturation of 100% on room air.

Two days later (PSD#10), the patient returned with hypoxia requiring intubation. She rapidly went into complete heart block, requiring CPR and cardioversion. Her previously normal LVEF was now 25%, with global hypokinesis. Acute phase reactant levels were markedly elevated. Lab-work indicated acute cardiac, liver and kidney injury, consistent with COVID-19-induced fulminant myocarditis and cardiogenic shock. CXR showed patchy bilateral infiltrates concerning for superimposed bacterial pneumonia. Through PSD#13, she required maximal doses of vasopressors. On PSD#14, we administered IV tocilizumab. She had mild clinical improvement.

On PSD#16, she suddenly decompensated, developing atrial fibrillation. X-rays showed dilated loops of bowel with pneumatosis. An emergent bedside laparotomy was performed. Her entire small bowel and colon was ischemic, with extensive necrosis. Shortly after, the patient developed asystole and was pronounced dead.

*Conclusions: Inflammatory or hypoxic disruption of myocardial pericytes in COVID-19 can result in microvascular dysfunction and cardiac ischemia which can precipitate heart failure. In the setting of a cytokine storm, this can lead to profound systemic shock and multisystem organ failure, with potentially fatal consequences in transplant recipients.

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