MYCOPLASMA GORDONAE: A RARE CAUSE OF ARDS IN THE IMMUNOCOMPROMISED

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Mycobacterium gordonae, a commonly found species of mycobacteria. While frequently encountered in the environment and clinical laboratories it is almost always considered nonpathogenic. Despite being a non-virulent organism, there are many cases of clinically significant disease. Occasionally, it has been known to cause severe infections, especially in patients with an underlying predisposition or immunosuppression such as AIDS. CASE PRESENTATION: A 39-year-old male with no known PMH presents to the hospital with complaint of worsening dyspnea, fever, and nonproductive cough. He was in his usual state of health until 3 weeks prior when he began to experience body aches, sore throat, fever and shortness of breath. Continued symptoms prompted visit to the hospital at which time he discharged from the emergency department. The patient continued to have progressive worsening of dyspnea with fever prompting return to the hospital and subsequent admission for acute hypoxic respiratory failure. He lives at home with his wife and 4 children who do not have similar symptoms. He has lived in the US for 17 years and denies recent travel, sick contacts, history of autoimmune diseases, smoking history, vaping history, drug use, skin rash, joint pain. On admission vital signs and physical exam showed tachycardia and tachypnea with fever and inspiratory rales. Laboratory data including comprehensive metabolic panel and complete blood count with differential was unrevealing. Chest imaging showed diffuse bilateral dense ground glass opacities. Inflammatory markers including D-dimer, Ferritin, LDH, CRP were elevated. Influenza, COVID-19, mycoplasma, legionella antigen resulted negative. Testing for HIV returned positive with a CD4 count of 8. Given the clinical picture the patient was started on steroids, Bactrim, and Highly active antiretroviral therapy (HAART). Bronchoscopy with BAL was performed showing negative cytology, negative GMS-silver stain. However, AFB testing showed positive M. gordonae with fungal culture showing Candida albicans. Prednisone was discontinued and the patient was continued on HAART therapy along with Bactrim and sent for further treatment with Infectious Disease specialists. DISCUSSION: While there are reports of M. gordonae infections involving many organ systems, pulmonary infection is the most common site of symptomatic disease. Common symptoms include cough, weight loss, dyspnea, hemoptysis and fever. In addition to clinical symptoms and radiographic abnormalities, positive cultures from sputum, bronchial wash, transbronchial or lung biopsy are necessary for diagnosis. CONCLUSIONS: M.gordonae is capable of causing significant infections in both immunocompromised and immunocompetent hosts. Although the likelihood of this being a contamination is significant, its isolation should prompt further evaluation especially in those patients who are immunocompromised. REFERENCE #1: Weinberger M, Berg SL, Feurstein IM, Pizzo PA, Witebsky FG. Disseminated infection with Mycobacterium gordonae: Report of a case and critical review of the literature. Clin Infect Dis. 1992;14:1229–1239. REFERENCE #2: Asija A, Prasad A, Eskridge E. Disseminated Mycobacterium gordonae infection in an immunocompetent host. Am J Ther. 2011 May. REFERENCE #3: Brener ZZ, Zhuravenko I, Bergman M. Acute kidney injury in a patient with nontuberculous mycobacterial infections: a case report. Cases J. 2009 Jan 23. DISCLOSURES: No relevant relationships by mohammed halabiya, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Shawn Pate, source=Web Response

From a cotton bud to a pool of blood COVID-19 testing, a double-edged sword?

Introduction: Coronavirus Disease 2019 (COVID-19) testing has grown exponentially in the United States since the dawn of the pandemic, with the vast majority of samples being obtained via nasopharyngeal swab. Although convenient and widely used, the test itself carries potential adverse effects, particularly those at high risk of bleeding. We present a patient who developed several arrays of complications after being tested for COVID-19 using the nasal swab sampling technique. Case Presentation: An 80-yo female presented from home with a complaint of hematuria. Her past medical history includes rheumatic heart disease status post repair on warfarin, atrial fibrillation and stroke. Vital signs were normal. She had benign head and neck exam, clear lung sounds, an irregular heart rhythm and a normal abdominal exam. Labs were at baseline with hemoglobin of 10.4. Chest x-ray and CT abdomen were unremarkable. She received a PCR nasopharyngeal swab in the emergency room and subsequently developed profuse epistaxis. Initial nasal packing and Afrin sprays failed to control the bleeding and she required emergent intubation for airway protection. She also needed vasopressors due to hypotension. Repeat hemoglobin was 7.5 and lactic acid was 10.4. Bleeding eventually stopped after continuous nasal packing, transfusional support and IV vitamin K. In the following days, she developed fever, leukocytosis and lung infiltrates. She received empiric antibiotic coverage, although no growth from cultures. Endoscopy findings were consistent with ischemic colitis. Later, she stabilized hemodynamically but was unable to be liberated from the ventilator. She was discharge to a long-term care facility after 43 days of stay. Discussion: Nasopharyngeal swabs are the mainstay of testing for COVID-19, however, little has been discussed regarding its procedural risks. Common adverse effects include headaches, nasal pain, ear discomfort and rhinorrhea. Recent studies have suggested that the incidence of epistaxis can be as high as 10% after the test. Alternatively, multiple research centers, including Yale and University of Illinois have released promising data on saliva-based testing. Their evidence supported high sensitivity comparable to the nasopharyngeal method with simpler and safer nature. Also, the saliva-based testing can be done at home, which is believed to reduce healthcare cost and lower the risk of cross infection. This case vividly demonstrates that even the most common procedure can result in devastating outcomes. As such, health care providers should be cognizant of these complications and consider alternative testing method when possible.

Complicated parapneumonic effusion due to esophagopulmonary fistula

INTRODUCTIONEsophagopulmonary fistula (EPF) is an improper communication between the esophagus and lung parenchyma. The the etiology of EPFs including esophageal malignancy with direct tumor invasion or post-radiation therapy (accounts for 50%), prolonged mechanical ventilation, infectious/inflammatory disease, caustic ingestion, trauma, or indwelling esophageal stent. Here we present a case of EPF complicated by parapneumonic effusion initially thought to be an empyema. CASE REPORTA 53-year-old male with past medical history of polysubstance abuse, HIV, perforated peptic ulcer s/p partial gastrectomy, and hypertension presented with productive cough, fever, unintentional weight loss, and non-bloody watery diarrhea for two days. He also reported difficulty swallowing liquids and occasionally solid foods for several months associated with cough during ingestion. Vital signs showed BP 116/74, HR 135, RR 29, temperature 102.1°F, and oxygen saturation 93% on room air. Physical exam revealed rales with decreased air entry of the right lung fields. Labs were significant for WBC 20,300, Hgb 7.9, Platelets 467,000, and procalcitonin 0.68. Urine drug screen and SARS-COV2 PCR were negative. ABG on room air with pH 7.369, pCO2 40.6, and pO2 65.1. Pleural fluid showed a WBC count 8375 and pH 7.0. CXR showed opacity in the right middle and lower lung. CT chest showed complex right pleural effusion with multiple areas of gas and atelectasis of right lower lobe with possible superimposed consolidation or areas of necrosis. Chest tube was placed with 600cc cloudy serous fluid determined to be exudative. Due to the clinical presentation, and signs of sepsis along with nature of pleural fluid, empyema was suspected. Pleural fluid culture was positive for gram negative rods, corynebacterium, and candida albicans. AFB culture and cytology were negative. However, due to nature of debris in esophagus and GI history, esophagram was performed which confirmed the presence of an EPF between the right distal esophagus and right lower lobe. The patient was initially treated with empiric antibiotics with de-escalation based on cultures. Unfortunately, after brief recovery, patient left the hospital against medical advice. DISCUSSIONThere are few cases reported involving a benign etiology being a cause of EPF as reported in this case. The patient had history of perforated peptic ulcer which is likely the underlying etiology. Due to this being a chronic issue, patient likely developed an infectious process which responded well to therapy. The relative uncertainty to the initial diagnosis and the underlying etiology behind this finding makes our case unique.