ABSTRACT
TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Pseudallescheria boydii is a fungal organism isolated from agricultural soil and polluted water. Pseudallescheria boydii (P. boydii) can rarely cause an invasive disease which is primarily seen in organ transplant patients.1 It is unusual for it to cause a pulmonary infection.1 We present a case of a patient admitted with COVID-19 who was found to be infected with P. boydii. CASE PRESENTATION: A 58-year-old male with a history of heart failure, deep venous thrombosis, stroke was admitted for altered mental status in the setting of sepsis. On admission he complained of dry cough and weakness. Lab findings were significant for lymphopenia, elevated inflammatory makers, anemia, and thrombocytopenia. Chest imaging was suspicious for COVID pneumonia;however, initial COVID-19 PCR was negative. He was started on steroids for suspected COVID pneumonia. 72 hours later there was a significant decline in his mental and respiratory status, requiring mechanical ventilation. A bronchoscopy with bronchoalveolar lavage (BAL) was performed with worsening interstitial infiltrates on chest x-ray and high index of suspicion for a fungal cause of his pulmonary insult. COVID 19 PCR was repeated, which was later found to be positive. Neurological workup with CT head, lumbar puncture and EEG were negative. We were concerned about COVID-19 encephalopathy. He was maintained on steroids for concern of organizing pneumonia. Repeat chest imaging was impressive for cavitary lesion. BAL culture sent earlier was growing a mold prompting utilization of voriconazole for concern of invasive aspergillosis. Final cultures from BAL revealed P. boydii, and he was switched to isavuconazole due to QTc prolongation. Post treatment repeat cultures were negative. DISCUSSION: Pseudallescheria boydiis is commonly seen in immunocompromised patients such as solid organ transplants. Clinical and histological features of P. boydiis and invasive aspergillosis are similar and can be difficult to distinguish in clinical practice. Optimal treatment for this infection has yet to be elucidated due to multiple resistance patterns to drugs such as amphotericin B. Studies have shown that combinations or high dose antifungals have higher success rates for treatment, but there is no regimen that is universally agreed upon.2 Based on literature review this is the first case of P.boydii pneumonia in a COVID-19 patient successfully treated with isavuconazole. CONCLUSIONS: Incidence of P.boydii is rare even in the transplant population and extremely rare to cause pulmonary infection. Additional studies must be done to better understand the pathogenesis and treatment of P. boydii to improve patient outcomes due to its severe morbidity and mortality. Based upon literature review this is the first successfully treated case of P.boydii by Isavuconazole. REFERENCE #1: Bibashi, E et al. "Invasive infection caused by Pseudallescheria boydii in an immunocompetent patient." Hippokratia vol. 13,3 (2009): 184-6. REFERENCE #2: Lackner M, de Hoog GS, Verweij PE, Najafzadeh MJ, Curfs-Breuker I, Klaassen CH, Meis JF. Species-specific antifungal susceptibility patterns of Scedosporium and Pseudallescheria species. Antimicrob Agents Chemother. 2012 May;56(5):2635-42. doi: 10.1128/AAC.05910-11. Epub 2012 Jan 30. PMID: 22290955;PMCID: PMC3346635. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Joanna DeAngelis, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Tania Ghorban Azar, source=Web Response No relevant relationships by Ryan Kowalsky, source=Web Response No relevant relationships by Aneeta Kumari, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Steven Miller, source=Web Response No relevant relationships by Karina Muzykovsky, source=Web Response No relevant relationships by Kunal Nangrani, source=Web Response No relevant relationships by Jose O sini, source=Web Response No relevant relationships by Gaurav Parhar, source=Web Response No relevant relationships by Evgeny Pinelis, source=Web Response Speaker/Speaker's Bureau relationship with Allergan Please note: $20001 - $100000 by Joshua Rosenberg, source=Web Response, value=Honoraria No relevant relationships by jad sargi, source=Web Response No relevant relationships by Viswanath Vasudevan, source=Web Response No relevant relationships by Kiran Zaman, source=Web Response