ABSTRACT
Introduction: Coccidioides immitis and posadasii are dimorphic fungi endemic to the southwestern United States. Most immunocompetent hosts who contract coccidioidomycosis will clear the infection without symptoms. We detail the case of an immunocompetent, 56-year-old female who presented with symptoms of lower respiratory tract infection and concern for COVID-19 infection given significant exposure history. Case Description: The patient was referred to our advanced lung disease center (located in the southwestern United States) for subacute, productive cough associated with clear-yellow phlegm, dyspnea on exertion, infrequent night sweats, and abnormal chest x-ray (Figure A). The patient denied any history of fever, chills, hemoptysis, unintentional weight loss, or chest pain. Six-weeks prior to admission, the patient had significant exposure to multiple symptomatic persons with COVID-19. Two RT-PCR tests for COVID-19 to date were ruled negative, and a third test performed on admission was also negative. Computed tomography of the chest revealed right upper lobe cavitary consolidation with surrounding nodules bilaterally (Figure B). Sputum smear was negative for acid-fast bacillus or other bacterial organisms, prompting a bronchoscopy with bronchoalveolar lavage. Results demonstrated fungal cultures of Coccidioides immitis/posadasii. The patient also had significant IgG antibodies against Coccidioides species. She was started on therapeutic doses of fluconazole with a gradual improvement in symptoms. Discussion: History of significant exposure to COVID-19 warrants prompt and thorough investigation for disease status. Nonetheless, clinicians should still maintain a high suspicion and vigilance for excluding other, potentially treatable infectious etiologies, even regional endemic fungal infections that tend to manifest without symptoms.
ABSTRACT
Introduction COVID-19 promotes inflammation and a hypercoagulable state. Antithrombotic therapies may be administered for thromboprophylaxis in those with severe infection requiring hospitalization. Spontaneous bleeding is an infrequent, yet life-threatening complication in patients receiving systemic anticoagulation. Case Report Two bilateral lung transplant recipients - 77-year-old female with idiopathic pulmonary fibrosis (patient A) and 69-year-old male with chronic obstructive pulmonary disease (patient B) - each presented with several days’ history of dyspnea, cough, and fatigue at 29-months and 11-months post-transplant, respectively;RT-PCR was positive for SARS-CoV-2 infection in both. Over the course of the next few days, patient A rapidly deteriorated with need for intubation despite initial treatment with antibiotics and corticotherapy. Patient B experienced gradual worsening of respiratory symptoms, which required high-flow oxygen supplementation and IV antibiotics. Inflammatory markers were elevated in both patients, and CT of the chest was consistent with atypical pneumonia in each. Patient A received convalescent plasma as a rescue therapy, and patient B received remdesivir with convalescent plasma. Given the hypercoagulable state in each, patient A and B received enoxaparin and IV heparin, respectively. Slowly, hemoglobin and platelet counts dropped in both patients, with need for transfusion and hemodynamic support. CT of the abdomen revealed a left gluteal intramuscular hematoma in patient A;CT of the chest, abdomen, and pelvis revealed a spontaneous chest wall hematoma and small area of retroperitoneal bleeding in patient B (Figure 1A and B). Summary These cases raise awareness for the viral-induced hypercoagulable state observed during the disease course. Clinicians should be cautious to avoid any hemorrhagic complications associated with thromboprophylaxis in selected cases, particularly in at-risk immunosuppressed patients.