ABSTRACT
SESSION TITLE: Severe and Unusual Blastomycosis Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Severe pulmonary blastomycosis (PB) usually affects immunocompromised patients, with very high mortality rate of up to 40%. PB can mimic pneumonia caused by other organisms (1), which can delay diagnosis and treatment initiation. We present a case of severe PB that was initially thought to be COVID-19 pneumonia, to our knowledge this is 2nd case of concomitant PB and COVID-19 infection in literature. (2) CASE PRESENTATION: Patient is 52 year old female with past medical history of atrial fibrillation, asthma, bariatric surgery, that presents with shortness of breath for 2 weeks. Despite receiving only 1 dose of COVID-19 vaccine (Moderna) 5 months ago, patient tested positive for COVID-19 on PCR test at the urgent care 4 days prior. Her symptoms progressed despite initial outpatient treatment with steroids and antibiotics. Initial emergency department chest computed tomography (CT) revealed dense bilateral consolidations, with hypoxic respiratory failure, patient was admitted for treatment of presumed COVID-19 pneumonia, and guideline directed treatment was initiated. Despite maximal medical management, that included steroids, broad spectrum antibiotics, remedisivir, patient failed to improve, with repeat CT chest revealing worsening consolidations. Bronchoscopy was performed 12 days into the admission revealed thick white secretions, with cultures growing blastomyces dermatitidis. At this point patient development of septic shock with multiorgan failure. Patient was subsequently intubated, and due to significant renal failure, initiated on hemodialysis (HD). Anti-fungal treatment was initiated with amphotericin B, and transitioned to itraconazole afterwards. Patient required several HD sessions, after which her renal function fully recovered. Patient was successfully extubated 7 days later, but required additional 22 days of medical care and physical therapy before being ready for discharge to rehabilitation facility. On the outpatient follow up 6 weeks after discharge, patient continues to slowly recover. Repeat CT chest still with significant bilateral consolidations. Patient will require at least 12 months of itraconazole therapy. DISCUSSION: PB can mimic bacterial and viral pneumonia symptoms. (1) In the widespread COVID-19 pandemic, clinicians can be misled by COVID-19 positive test in patient with bilateral pneumonia, and initiate guideline directed therapy. Immunosuppression agents can lead to adverse outcomes in patients with underlying PB. Questionable is the significance of COVID positive PCR test in semi-vaccinated individual. Potentially even mild COVID-19 infection could predispose patient for PB. Early diagnosis of PB is important, as delay in treatment and medical immunosuppression can lead to worse outcomes. CONCLUSIONS: PB should be suspected even in patients presenting with positive COVID-19 PCR test. Guideline directed therapy for COVID-19 can worsen underlying PB. Reference #1: https://www.cdc.gov/fungal/covid-fungal.html Reference #2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8503152/ DISCLOSURES: No relevant relationships by Dovile Baniulis No relevant relationships by Dovile Cerkauskaite No relevant relationships by Igor Dumic No relevant relationships by Momcilo Durdevic No relevant relationships by Dragana Durdevic No relevant relationships by Ashutossh Naaraayan No relevant relationships by Ankita Subedi
ABSTRACT
SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Acute kidney injury (AKI) is a major complication in the Coronavirus disease 2019 (COVID-19). We present a group of patients who, after requiring mechanical ventilation (MV) for COVID-19 respiratory failure, precipitously developed progressive AKI within 24 hours of intubation. METHODS: Patients with confirmed COVID-19 and respiratory failure requiring MV were included. Patients with a history of chronic kidney disease stage 3 or higher and end-stage renal disease were excluded. Data was collected from the hospital medical records. AKI diagnosis and staging were determined as per the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. RESULTS: A total of 15 patients were identified who had progressive AKI after being intubated for COVID-19 respiratory failure. The median age of patients was 58 years [interquartile range (IQR) 52-65], 8 (53%) were men and average body-mass-index (BMI) was (32.9+9.9). Most common comorbidities were: hypertension 9 (60%), hyperlipidemia 6 (40%) and diabetes 6 (40%). The median hospital day when intubation was performed was 3rd day (IQR 2-4). MV was conducted according to ARDS mechanical ventilation guidelines. None of the patients required vasopressors before MV, whereas, after intubation 13 patients (87%) required vasopressors. The median number of vasopressors used was 2. All patients received propofol for sedation, with the addition of morphine in 12 patients, midazolam in 5 patients, fentanyl in 4 patients, and hydromorphone in 1 patient. Paralytics were used in 7 patients. The median intensive care length of stay was 9 days (IQR 5-12). All the patients had an elevated d-dimer [median 4300ng/ml (IQR 1662-25303), normal <230 ng/ml] and C-reactive protein (CRP) levels [median 343 mg/l (IQR 313-390), normal <8mg/l]. 11/15 (73%) patients either received dialysis or had indications for dialysis and 12/15 (80%) patients died. CONCLUSIONS: Patients with COVID-19 respiratory failure are at an increased risk for AKI with the initiation of MV. While on MV, these patients had a high requirement for dialysis and a high mortality rate. CRP and d-dimer were markedly elevated in all of these patients. Possibly, oxygen toxicity and capillary endothelial damage with continuing high-pressure in the lungs from MV, triggered an inflammatory and thrombotic state leading to hypotension, sepsis, and subsequent AKI. Other possible mechanisms for AKI could be direct viral cytotoxicity and iatrogenic causes (drugs). Correlation between the initiation of MV and AKI is peculiar and its pathophysiologic mechanisms need to be fully understood. CLINICAL IMPLICATIONS: Because of the temporal association of severe AKI with the initiation of MV and possible causative role of MV in illness severity and death, physicians should strongly consider noninvasive respiratory support such as high flow nasal cannula in respiratory failure with COVID-19. DISCLOSURES: No relevant relationships by Maria Bernal Riera, source=Web Response No relevant relationships by Momcilo Durdevic, source=Web Response No relevant relationships by Dragana Durdevic, source=Web Response No relevant relationships by Amrah Hasan, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Ashutossh Naaraayan, source=Web Response No relevant relationships by Abhishek Nimkar, source=Web Response No relevant relationships by Andreea Constanta Stan, source=Web Response