In March 2021, Alonna Mushenski started coughing — a lot.
At first, she didn't think anything of it. As a smoker, she coughed every morning anyway. And she didn't have the classic symptoms of the virus that kept the world isolated over the previous year. Her head hurt, and her nose dripped, but both of these issues seemed more like signs of allergies. Yet, on her fourth day of symptoms, a rapid test confirmed that she had developed COVID-19.
The 21-year-old wasn't worried about herself. She was young and relatively healthy. But her mother, Karey Mushenski, had undergone a lung transplant a few weeks before. Like others whose immune systems are weakened, Karey was at high risk of not only contracting COVID but of being hospitalized and even dying from it. And Alonna had been taking care of Karey during her recovery.
"I took drinks out of her drink," Karey said. "I should have caught it."
Yet Karey never developed symptoms of COVID and tested negative for the coronavirus that has produced more than 191 million infections worldwide. In fact, while Alonna wheezed trying to climb the stairs, Karey felt better than she had in more than a decade.
Karey had received both shots of the COVID vaccine before she was ever put on the waiting list for a lung transplant, a planned effort by her physicians at the University of Michigan Transplant Center to ensure that Karey could build up immunity before she started taking medications that would suppress her immune system for the rest of her life.
"If she had not been vaccinated beforehand, being in the same household with a COVID-positive family member that was intimately in contact with her would have certainly led to her turning positive for COVID," said Dennis Lyu, M.D., the director of lung transplantation at Michigan Medicine and a clinical associate professor in the division of pulmonary and critical care medicine at the University of Michigan Medical School. "And being a freshly transplanted patient, acquiring COVID carries a very high mortality rate."
"Being vaccinated pre-transplant essentially saved her life," he said.
Being a freshly transplanted patient, acquiring COVID-19 carries a very high mortality rate. Being vaccinated pre-transplant essentially saved Karey's life.Dennis Lyu, M.D.
Out of breath
Karey first realized her body was overly stressed 10 years ago, when she was in her early 30s.
At first she chalked up her mounting exhaustion to working two jobs; she split her time between driving public buses and delivering mail for the United States Postal Service. Then, after struggling to breathe during a softball game, she figured her smoking habit must be affecting her lung function.
Karey's cigarettes went in the trash, but quitting smoking didn't seem to make a difference: Six months later, she needed to take a leave of absence from her job at the post office because it had become too physically demanding for her body to handle. She didn't have health insurance, so she was reluctant to go to the doctor.
When she did seek medical care, she asked the provider to put a pulse oximeter, which estimates how well oxygen is circulating throughout the body, on her finger. Her stats were so low that he told her to go to the emergency room.
Several specialists and tests later, MeiLan Han, M.D., a professor of medicine in the division of pulmonary and critical care at the University of Michigan Medical School, diagnosed Karey with lymphangioleiomyomatosis, or LAM. LAM is a rare disease that can produce cysts in the lungs, restricting air from moving in and out like it should, or cause fluid build-up that makes it difficult to breathe.
Han is also the co-director of the only LAM Foundation-certified LAM clinic in the state of Michigan. Her LAM patients are mostly female and tend to be diagnosed with the condition in their mid-30s, around Karey's age. Nationally, a disease is considered rare if it affects roughly 1 in about 1,500 people; estimates suggest that between 3 and 8 women in a million have LAM.
"It's only at a place like the University of Michigan where you're going to amass the expertise for something that's this rare," Han said.
Early on in their interactions, Han told Karey that she might eventually need a lung transplant.
"I worry more about my LAM patients who are younger at the time of diagnosis," Han said. "Karey was pretty young at the time I first met her and given how severe her disease was, no matter what we did, I suspected that at some point seeking a lung transplant would be her best hope."
But there were various factors to consider, including the risk of rejection for transplanted lungs, which is higher than other organs given the number of opportunities lungs have for infection. (Research is ongoing at Michigan Medicine and elsewhere to decrease the rejection rate and improve survival after lung transplants.)
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Karey was able to live for 10 more years with her own lungs and help from medication. But over time, she needed more and more supplemental oxygen to breathe normally. She ended up struggling to complete basic tasks, like taking a shower, and had to stop working and taking college classes in order to go on disability.
Eventually, the results from several of Karey's tests were poor enough for Michigan Medicine to start evaluating her for a lung transplant. It took a month or two of additional tests and meetings with pre-transplant coordinators, social workers, financial coordinators and surgeons to assess whether Karey was a good candidate for the procedure.
Time for the shot
After that process was complete, Karey had a little longer to wait, as her Michigan Medicine physicians told her that she should get the COVID vaccine before being put on the transplant list. Transplant patients need to take medications that keep their bodies from rejecting their new organs by intentionally weakening their immune systems. This makes it easier for them to become sick with contagious illnesses such as COVID and may also reduce their antibody response, an element of the immune system, to vaccines.
But the immune system has many components, including cells that can help the body remember when it's seen an invading bacteria or virus before and what to do in order to defend against it. These "memory cells" can protect Karey and other transplant patients from infections, even if other parts of their immune systems aren't working as well post-transplant.
"Even when the antibody levels drop, your body and your immune system still has the memory where when they see that virus again, they can ramp things up again quickly," said Jules Lin, M.D., the surgical director of the lung transplant program at Michigan Medicine and a professor in the section of thoracic surgery at the University of Michigan Medical School. "That's how it is for a lot of different infections, so there are probably similar mechanisms behind the protection against COVID."
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But the memory cells are more likely to develop in the first place if patients are vaccinated or exposed to a virus or other threat when their immune systems are stronger — which is why it would be best to give patients the COVID vaccine before transplant. (Early research has shown that immunosuppressed patients getting vaccinated after transplants have some of the lowest immune system responses to the COVID vaccine.)
Yet Karey wasn't eager to get vaccinated. She believed the vaccine had been developed too quickly, that it hadn't been tested enough.
"They don't even know the ins and outs of COVID," she said. "How can they make the vaccine to conquer it, you know?"
But the prospect of having to fight off the coronavirus with a frail immune system post-transplant convinced her to get the shots.
Karey was able to receive the Pfizer-BioNTech vaccine from the health department in her county, thanks in part to her family medicine physician advocating for her. (The shots were technically only available for those 65 and older at the time.) She received her two doses three weeks apart and experienced virtually no side effects after either one.
Two weeks after her second dose, she was listed for a transplant. It took just four days for her to get the call that a pair of lungs were waiting for her. (The typical wait for a transplant at Michigan Medicine is a few months to a year.)
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"I think I screamed a little," Karey said. "I thanked God. I cried. I laughed. I shouted. It was a crazy amount of emotions."
'I'm a true believer'
Karey's transplant went smoothly, and her healing was going well, even better than expected. She felt lighter, literally — the oxygen tank she'd been toting around everywhere was heavy. Suddenly, she no longer needed it.
"We, in some sense, get used to seeing these patients, but you never really get used to seeing how much it really can benefit some of them," said Lin, who did Karey's transplant.
And Karey was just as happy with the care she received at Michigan Medicine.
"There was no one person making a decision. It was a team," she said. "I felt like I had all those brilliant minds working as one to save my life. How can you go wrong with that?"
When her daughter contracted COVID, that brought Karey's optimism down a notch. (Alonna had to cope with dizziness and shortness of breath for a while, but she's now feeling good enough to hang out with her mom again.)
But Karey didn't stress too much about the situation because she never contracted COVID-19, a feat she credits to getting vaccinated.
"I get why a lot of people are skeptical of the vaccine," Karey said. "I was one of those people. But getting the vaccine and then not getting sick when I should have, that turned me around. That's when I was like, 'OK, I'm a true believer.'"
And the protection she gets from being vaccinated allows her the opportunity to gradually craft a new life, one where she hopes to immerse herself in nature, buy a motorcycle and travel to Hawaii.
"I feel like I'm doing really good," she said. "I think it's possible for me to keep going another 20 years. That's what I want anyways. I just want to live."