**1. Introduction**

Coronavirus disease 2019 (COVID-19), an infectious respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread on a pandemic scale since the first case was reported in Wuhan, China, in 2019 [1]. Most patients with the disease have mild-to-moderate symptoms; however, approximately 15% develop severe pneumonia, while approximately 5% develop acute respiratory distress syndrome (ARDS), septic shock, and/or organ failure [2]. Lymphopenia is a recurrent feature in these patients, with a significant reduction in CD4+ T cells, CD8+ T cells, B cells, and natural killer (NK) cells [3], increasing the susceptibility of patients to severe illness and co-infection [4]. In fact, co-infections are associated with worsening of the clinical condition [5].

Chagas disease (CD) is a zoonosis whose etiologic agen<sup>t</sup> is the protozoan *Trypanosoma cruzi*. It is estimated that 6–8 million people worldwide are infected [6]. CD has two distinct phases: an acute one, which is rare, with a strong production of type 1 cytokines, and a

**Citation:** Gozzi-Silva, S.C.; Benard, G.; Alberca, R.W.; Yendo, T.M.; Teixeira, F.M.E.; Oliveira, L.d.M.; Beserra, D.R.; Pietrobon, A.J.; Oliveira, E.A.d.; Branco, A.C.C.C.; et al. SARS-CoV-2 Infection and CMV Dissemination in Transplant Recipients as a Treatment for Chagas Cardiomyopathy: A Case Report. *Trop. Med. Infect. Dis.* **2021**, *6*, 22. https://doi.org/10.3390/tropicalmed 6010022

Received: 16 January 2021 Accepted: 8 February 2021 Published: 10 February 2021

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chronic phase, which develops in 30–40% of CD cases. The chronic phase of CD can be characterized by cardiomyopathy, arrhythmias, megaviscera, and, more rarely, polyneuropathy and stroke [7]. TCD4+ and TCD8+ lymphocytes are the main cells responsible for controlling parasitic infection. However, the immune response also contributes to tissue damage and pathology [8].

Chagasic cardiomyopathy represents the main cause of mortality from this disease, which can lead to heart failure, whose indication for treatment, especially in endemic countries, may include heart transplantation (HT) as a strategy to curb the evolution of this complication [6,9]. However, the immunosuppression and possible reactivation of the causative agen<sup>t</sup> *T. cruzi* following HT require intensive clinical care and laboratory monitoring [10].

Other infections such as that caused by cytomegalovirus (CMV), a herpes virus that infects up to 60–100% of people in adulthood, are associated with transplant complications [11]. Primary CMV infection is generally asymptomatic in immunocompetent individuals, with the virus generating a latent infection. On the contrary, in immunocompromised and immunosuppressed populations, such as solid organ transplantation, hematopoietic stem cell transplantation, and HIV/AIDS patients, CMV reactivation is responsible for significant morbidity and mortality [12]. Although reactivation of infections such as CMV and CD are often described in transplant recipients, there are no reports of concomitant infection by *T. cruzi*, CMV, and SARS-CoV-2 in the context of HT in the literature to date.

Therefore, in this report, we investigated the progress of two patients who underwent HT at the Heart Institute of Hospital das Clínicas (Incor) and were subsequently transferred to the special intensive care unit (ICU) of the Hospital das Clínicas (Hospital das Clínicas, Faculty of Medicine, University of São Paulo-HCFMUSP) due to SARS-CoV-2 infection. These patients were diagnosed with COVID-19 by nasopharyngeal detection of SARS-CoV-2 RNA using reverse transcriptase polymerase chain reaction (RT-PCR). In addition, during hospitalization, CMV dissemination was evidenced by quantitative DNA detection in the blood. We describe herein the laboratory data from the first day of hospitalization due to COVID-19 until the death of the patients.

The baseline characteristics of these two patients, as well as their past clinical data, are summarized in Table 1.


**Table 1.** Patients' characteristics, comorbidities, treatment, and complications.


**Table 1.** *Cont.*

ARD, acute respiratory distress syndrome; COVID-19, coronavirus disease 2019; ICU, intensive care unit; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
