ABSTRACT
Invasive aspergillosis is a rapidly progressive, fatal infection that usually occurs in immunocompromised patients. The spectrum of clinical presentation ranges from non-invasive, invasive, destructive and allergic aspergillosis. It is rare to see overwhelming aspergillosis in an immunocompetent host. Nevertheless, certain risk factors such as underlying fibrotic lung disease, suppurative infection, long-term corticosteroid use and uncontrolled diabetes mellitus (DM) have been described. We hereby present a case of invasive pulmonary aspergillosis in a patient with uncontrolled DM. A 60-year-old man with a history of heavy smoking (50- pack-year), poorly controlled DM presented to the hospital with a large area of erythema with eschar over his left posterior thigh. Clinical examination and CT abdomen pelvis confirmed necrotizing fasciitis involving his perineum and left thigh. Admission CT abdomen showed a small left lower lobe infiltrate (Day 1, Panel A). He underwent urgent debridement and intraoperative tissue cultures grew coagulase-negative staphylococcus, Proteus Vulgaris and anaerobic gram-positive rods. He received piperacillintazobactam, vancomycin, and clindamycin for 16 days which was subsequently narrowed to ceftriaxone and metronidazole. He had worsening leukocytosis but all his blood cultures have been negative. Tracheal aspirate gram stain on day 5 showed moderate yeast, and cultures grew Candida albicans and Aspergillus fumigatus. CT scan of his chest showed bilateral reticulonodular opacities with a new loculated right pleural effusion (Day 16, Panel B). Trans-esophageal echocardiogram did not show any right-sided heart valve vegetation. He received intravenous voriconazole for disseminated aspergillosis. Despite of new prophylactic antifungal strategies, more sensitive and rapid diagnostic tests, as well as various efficacious treatments, survival of invasive disseminated aspergillosis remains poor. High clinical suspicion with a proactive investigation approach is the key to minimizing mortality. Various risk factors such as hematopoietic-cell transplantation, neutropenia, solid-organ transplantation, chemotherapy, prolonged ICU stay, structural lung disease, impaired mucociliary clearance after a recent pulmonary infection (including SARS-CoV-2) have been well described. Our case highlights the importance of recognizing uncontrolled DM as a crucial risk factor for disseminated aspergillosis. (Figure Presented).
ABSTRACT
Background: Patients with COVID are more likely to have systemic thrombotic events. Although it has been theorized that those on CRRT also have an increased rate of filter loss due to clotting. If COVID-positive patients are more likely to clot their filter than other patients on CRRT, a more aggressive anticoagulation strategy may be worthwhile. This could result in longer filter lifespan, less circuit down time, which would result in improved clearance, lower costs, less risk of iatrogenic blood loss, and less wasted nursing time. If there is no difference in filter lifespan between COVID positive and negative patients, then more aggressive anticoagulation would result only in added risk without a clear benefit. Methods: We analyzed COVID data on patients in a related unblinded prospective randomized trial, in which patients are assigned to either pre-filter CVVH or CVVHD. The standard treatment protocol at the University of Iowa is to use citrate anticoagulation with a blood flow rate of 200 mL/min and a dose of 25 mL/kg/hr. The primary outcome is average filter life, and secondary outcomes are mortality, intensive care unit LOS, hospital LOS, and renal recovery. Results: A total 30 patients using a total of 90 filters from March 25 to May 20, 2020 were evaluated (Table 1). The average filter life in COVID-positive patients was 37.4 +/- 35.8 compared to 33.1 +/- 26.7 in COVID-negative patients (p = 0.55). However, COVID-19 patients were more likely to receive heparin anticoagulation in addition to citrate. Conclusions: Contrary to other reports, in this retrospective, unadjusted analysis of CRRT patients, the presence of COVID-19 did not decrease average filter life. Further research is needed regarding the appropriate anticoagulation strategy in COVID-19 positive patients.