ABSTRACT
SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multiple pleural complications have been well described during COVID-19 infection including pneumothorax, pleural effusion and empyema. While many infections have been described as complications, here we present a case of empyema secondary to Enterococcus faecium in a patient with COVID-19 after Extra-corporeal membrane oxygenation (ECMO). CASE PRESENTATION: A 33-year-old male presented with acute respiratory distress syndrome secondary to COVID-19. He was intubated 10 days after symptom onset and subsequently placed on veno-venous ECMO, with reconfiguration to add an arterial return limb and eventually pulmonary artery return limb. During his care he was treated with remdesivir, dexamethasone and tocilizumab. His course was complicated by right heart failure requiring mechanical support, acute renal failure requiring hemodialysis, superior vena cava thrombus, multi-drug resistant Pseudomonas, Enterococcus faecalis, Klebsiella and methicillin sensitive Staphylococcus aureus infections. Eventually he was removed from ECMO on day 130. The patient remained in the ICU on positive pressure ventilation via tracheostomy. He eventually developed worsening respiratory status as well as signs concerning for an emerging infection. Broad spectrum antibiotics were initiated, and a CT chest/abdomen/pelvis was obtained that showed right pleural effusion with concern for empyema. Pleural sampling was consistent with empyema with glucose <5 mg/dL, pH <7.2, lactate dehydrogenase >200 U/L and an elevated neutrophil count. A percutaneously placed 14 french chest tube was placed and pleural irrigation with normal saline was trialed given patient need for continuous systemic anticoagulation. However, this did not sufficiently resolve the empyema and patient was started on pleural TPA/Dornase with close monitoring while on anticoagulation with clinicoradiographic improvement after a total of 6 days of therapy. Cultures eventually speciated as Enterococcus faecium and he was continued on a 6 week course of ampicillin for his empyema. DISCUSSION: Classically, Enterococcus empyema has been primarily linked with intra-abdominal infections which was not found in our patient and has not been correlated with COVID-19 infection or ECMO. Additionally, there is a significant paucity of data with regards to safety of TPA/Dornase pleural irrigation use while patients are on full dose systemic anticoagulation as was our patient. In this case he required two 3-day courses of TPA/Dornase which was tolerated well without significant complication. CONCLUSIONS: Here we describe a rare causative organism of empyema that has not been previously described in the literature as associated with COVID-19 or ECMO. Additionally, we demonstrate the safety of intra-pleural TPA/Dornase in this patient on full dose anticoagulation which is a frequent consideration when determining the method of treating empyema in complex medical patients. Reference #1: Ayad S, Gergis K, Elkattawy S, et al. Loculated empyema and SARS-COV-2 infection: A report of two cases and review of the literature. European journal of case reports in internal medicine. July 2021;8(7):002706. doi:10.12890/2021_002706. Reference #2: Bergman R, Tjan DH, Schouten MA, Haas LE, van Zanten AR. Pleural Enterococcus faecalis empyema: an unusual case. Infection. Feb 2009;37(1):56-9. doi:10.1007/s15010-007-6359-6 Reference #3: Rahman NM, Al. E, Author Affiliations From the United Kingdom Clinical Research Collaboration Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection: Nejm. New England Journal of Medicine. Nov 2011;365:518-526. doi:10.1056NEJMoa1012740. DISCLOSURES: No relevant relationships by Joshua Boster No relevant relationships by Mary Gadarowski No relevant relationships by Stephen Goertzen No relevant relationships by Amanda Hall No relevant relat onships by Erik Manninen