**4. Conclusions**

This report highlights the first case of an association between COVID-19, CD, and CMV dissemination in HT recipients. The patients had rapid disease progression to death. We believe that HT and the usage of immunosuppressive drugs, as well as immunosuppression generated by concomitant infections, may be an important risk factor for the development of severe COVID-19, especially in endemic areas with underreported CD infection.

**Author Contributions:** Conceptualization, S.C.G.-S., G.B., and R.W.A.; investigation, S.C.G.-S., G.B., R.W.A., T.M.Y., F.M.E.T., L.d.M.O., D.R.B., A.J.P., E.A.d.O., A.C.C.C.B., M.M.d.S.A., I.G.F., N.Z.P., Y.Á.L.R., J.C.L., B.P., and S.M.; resources, M.N.S. and A.J.d.S.D.; writing—original draft preparation, S.C.G.-S., G.B., and R.W.A.; writing—review and editing, S.C.G.-S., G.B., and R.W.A.; visualization, S.C.G.-S., G.B., R.W.A., T.M.Y., F.M.E.T., L.d.M.O., D.R.B., A.J.P., E.A.d.O., A.C.C.C.B., M.M.d.S.A., I.G.F., N.Z.P., Y.Á.L.R., J.C.L., B.P., S.M., A.J.d.S.D., and M.N.S.; supervision, M.N.S.; funding acquisition, A.J.d.S.D. and M.N.S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by Fundação de Amparo à Pesquisa (FAPESP), gran<sup>t</sup> numbers 2019/22448-0, 19/02679-7, 2017/18199-9, 2018/18230-6, and 2019/26928-6. Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES:88887.503842/2020-00.

**Institutional Review Board Statement:** This study was approved by the local ethics committee (HCFMUSP n<sup>º</sup> 30800520.7.0000.0068-2020) and was carried out in accordance with the 2013 revision of the Declaration of Helsinki.

**Informed Consent Statement:** Informed consent was obtained from all of the subjects involved in the study.

**Data Availability Statement:** The laboratory data and imaging exams presented herein came from Hospital das Clinics, Faculty of Medicine, University of São Paulo (HCFMUSP) with prior approval for their use.

**Conflicts of Interest:** The authors declare no conflict of interest.
