• David Bennett, Federico Franchi, Elda De Vita, Maria Antonietta Mazzei, Luca Volterrani, Maria Giulia Disanto, Guido Garosi, Andrea Guarnieri, Maria Grazia Cusi, Elena Bargagli, Sabino Scolletta, Serafina Valente, Roberto Gusinu, and Bruno Frediani.
• Respiratory Diseases Unit, Department of Medical Sciences, University Hospital of Siena (Azienda Ospedaliera Universitaria Senese, AOUS), Siena, Italy.
• Postgrad Med. 2021 Jun 1; 133 (5): 540543540-543.

AbstractCoronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has quickly spread all over the globe from China. Pleural involvement is not common; around 5-10% of patients can develop pleural effusion and little is known about the involvement of pleural structures in this new infection.A 61-year-old male kidney transplant patient with a history of multiple biopsy-confirmed acute rejections and chronic allograft rejection was admitted to our COVID-19 Unit with dry cough, exertional dyspnea, oliguria, and abdominal distension. Lung ultrasound imaging, chest X-ray, and CT scan showed left pleural effusion and atelectasis of the neighboring lung parenchyma. RT-PCR was positive for SARS-CoV-2 in the pleural fluid and cytology showed mesothelial cells with large and multiple nuclei, consistent with a cytopathic effect of the virus.This is one of few reports describing detection of SARS-CoV-2 in the pleural fluid and to the best of our knowledge, is the first to document the simultaneous presence of a direct cytopathic effect of the virus on mesothelial cells in a kidney transplant patient with COVID-19 pneumonia. The pleura proved to be a site of viral replication where signs of a direct pathological effect of the virus on cells can be observed, as we report here. RT-PCR for SARS-CoV-2 should be part of routine examination of pleural effusion even in patients with mild respiratory symptoms or with comorbidities that seem to explain the cause of effusion.

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