Cryptococcal Infection Following COVID-19 infection in Solid Organ Transplant Recipients: A Case Series

Background. Fungal infections have been identified with or following SARSCoV-2 infection, most commonly COVID associated pulmonary aspergillosis. Cryptococcus species are ubiquitous in the environment and the third most common invasive fungal infection following Solid Organ Transplant (SOT). We describe four cases of concurrent or subsequent cryptococcal infection within 90 days following COVID-19 infection. Methods. We conducted a retrospective study of patients presenting with proven cryptococcosis either concurrently or within 90 days following COVID-19 diagnosis. Cases were identified March 2020 through May 2021. All were seen at the University of Alabama in Birmingham, a regional referral and comprehensive transplant center. Exemption for this review was approved by our IRB. Results. Four cases were identified, all were SOT recipients. Case details are provided in Table 1. No patients required ICU level care at any point. COVID-19 treatment included 10 days of increased steroids for 3 patients, remdesivir for 2, and 1 received no treatment for COVID-19. In contrast to the typical time-course for cryptococcal infection post-SOT (median time approx. 500 days post-transplant), three patients were greater than 2 years post-transplant and were without rejection or recent changes in immunosuppression. Patient 1 was less than 6 months post liver-kidney transplant and was diagnosed at time of admission with concurrent COVID-19 and cryptococcal pneumonia. Infection was disseminated in the other 3 cases including positive blood cultures in 2 patients and cryptococcal meningitis (CM) in 2 patients. CM cases presented later following COVID-19 and had the longest delay between symptom onset (headache, neurologic symptoms) and CM diagnosis. One patient had CM 8 years prior, but had done extremely well off fluconazole for over 6 years prior to this recurrence. All patients are doing well at most recent follow-up evaluations. Conclusion. We describe the first case series with a temporal association between SARS-CoV-2 infection and cryptococcosis. All cases were immunocompromised due to SOT. Some symptoms were attributed to post-COVID syndrome leading to significant delays in diagnosis for those patietns, highlighting the importance of considering this association for at-risk patients.

1,2,3: Use of Ang II in a HM3

Introduction Vasodilatory shock is characterized by peripheral vasodilation, hypotension and preserved cardiac output. Management involves identifying and treating the underlying cause and reestablishing adequate blood pressure. Contemporary vasopressors include catecholamines and vasopressin, and their use is limited by adverse effects. Adjunctive use of Angiotensin II (Ang II) has been shown to increase mean arterial pressure (MAP) in patients with vasodilatory shock. We describe the first successful use of Ang II in a patient with a HM3 left ventricular assist device (VAD). Case Report 58-year-old gentleman with long-standing NICM, LV EF 20-25%, atrial fibrillation (AF), CKD stage III, recent COVID-19, presented with an ST elevation myocardial infarction and progressed to refractory cardiogenic shock. He was supported with inotropes and an intra-aortic balloon pump and implanted with a HM3. VAD course was complicated by right ventricular dysfunction, respiratory failure, and renal failure, necessitating initiation of continuous dialysis. Patient developed sepsis due to clostridium dificile colitis and pneumonia that progressed to refractory vasodilatory shock on post-op day 20. He was supported on HM3 at 5600 rpm, inotropes and escalating doses of pressors. He developed AF with rapid ventricular response, limiting further uptitration, thus, Ang II was initiated. Initial dose was 20 ng/kg/min, with a robust response in MAPs from 60s to 80s mmHg in 2 minutes. Within 24 hours he was weaned off of Ang II and within 72 hours, he was weaned off of all pressors (Table). He was subsequently transitioned to HD and weaned off of inotropic and ventilatory support. Summary Treatment options for patients with catecholamine-resistant vasodilatory shock are limited. In patients with refractory vasodilatory shock supported with durable LVAD therapies, information on the use of Ang II is limited. In our patient with multi-system organ failure and impending death, we were able to utilize Ang II to provide hemodynamic stability and rescue him from septic shock.

Management of Post Infarction Ventricular Septal Rupture in Contemporary Era

Introduction: During the COVID-19 pandemic, there has been an increase in mortality and complications following STEMI. The rarity of ventricular septal rupture (VSR) in the age of primary percutaneous coronary intervention has resulted in a lack of expertise in its management. Our strategy has been to stabilize patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) then evaluate for surgical repair with revascularization as well as advanced options, such as heart transplantation. Here we present two cases. Case 1: A 65-year-old man with a history of hypertension presented to the hospital with an inferior STEMI and cardiogenic shock. He was found to have acute occlusion of the right coronary artery (RCA) through which a wire was not able to be passed. He also had severe disease in the left anterior descending artery (LAD) and left circumflex artery (LCx). An intra-aortic balloon pump (IABP) was placed. On hospital day 6, hemodynamics worsened and he was found to have a large VSR of the basal inferoseptum and biventricular dysfunction with a left ventricular ejection fraction (LVEF) of 10-15%. He was placed emergently on VA ECMO. Ten days later, he underwent repair of VSR and coronary artery bypass grafting (CABG) with a left internal mammary artery (LIMA) to LAD, and saphenous vein graft to an obtuse marginal. He underwent ECMO decannulation on post operative day 6. He was discharged home on post operative day 23 on medical therapy with an LVEF of 35%. He remains on medical therapy at 6 months. Case 2: A 43-year-old man with a history of hypertension and diabetes suffered an inferoposterior STEMI. Coronary angiography showed acute occlusion of the RCA. He underwent thrombectomy and placement of two bare metal stents with no reflow, and placement of an IABP. He also had chronic occlusion of the LCx and 80% stenosis in the proximal LAD. A post procedure echocardiogram showed LVEF of 35-40%, severe right ventricular dysfunction, and VSR in the mid inferoseptum. He had worsening cardiogenic shock and underwent VA ECMO placement. On hospital day 9, he underwent VSR repair and single vessel CABG with LIMA to LAD. Due to inability to wean off bypass, he required placement of dual-pump biventricular support with Centrimag pumps after which he had persistent ventricular tachycardia. He was listed status 1A and underwent successful heart transplantation on hospital day 20. He is doing well at follow up. We presented two cases of ventricular septal rupture complicating myocardial infarction, both with successful outcomes. During the COVID-19 pandemic, clinicians will need to maintain a high index of suspicion of mechanical complications of late presenting STEMI.