ABSTRACT
TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Roseomonas genus was described in 1993 by Rihs et al. as a "pink coccoid", non-fermentative, aerobic, gram-negative bacteria. It has been isolated from environmental sources (e.g., water, soil, air, and plants);however, human infections are rare. We report a case of R. gilardii associated bacteremia in the setting of COVID-19 pneumonia. CASE PRESENTATION: 73-year-old man with history of HIV (on Bictarvy, well controlled), and diabetes presented with progressive shortness of breath. On admission he was tachypneic, hypoxic, and tachycardic. Lab findings showed lactic acidosis, leukocytosis, respiratory acidosis, elevated inflammatory markers, and COVID-19 PCR positive. He was in acute hypoxic respiratory failure requiring escalation of oxygen therapy with eventual intubation. CT angiography of the chest showed diffuse bilateral subpleural ground glass opacities and lower lobe consolidation with air bronchogram. He was started on Dexamethasone 6mg (10 days), Remdesevir (1 dose), and empiric antibiotics for pneumonia. After 5 days of above therapy patient continued to deteriorate and plasma exchange was given as a salvage therapy. Blood cultures from admission grew Roseomonas Gilardii, which was susceptible to Cefepime. After literature review cefepime was switched to imipenem, cilastatin and amikacin due to studies suggesting high amounts of resistance to Cephalosporins. DISCUSSION: Majority of infection due to R. spp occur in immunocompromised patients (e.g., ESRD, cancer and transplant). These organisms are susceptible to quinolones, carbapenems, and cephalosporins with recommended duration of treatment being 15 days. R. mucosa isolates are resistant to ceftazidime, cefepime, piperacillin, tazobactam, and colistin. R. gilardii is more susceptible than R. mucosa to tested antimicrobial agents. CONCLUSIONS: This is the first reported case of R. gilardii associated empyema in a COVID-19 patient. This underlines the impact of superinfections in COVID-19. R spp. infection in humans is rare and have an inherent resistance to cephalosporins, but high susceptibility to Amikacin and Imipenem. REFERENCE #1: Rihs JD, Brenner DJ, Weaver RE, Steigerwalt AG, Hollis DG, Yu VL. 1993. Roseomonas, a new genus associated with bacteremia and other human infections. J. Clin. Microbiol. 31:3275–3283. REFERENCE #2: Petros Ioannou, Vasiliki Mavrikaki & Diamantis P Kofteridis (2020). Roseomonas species infections in humans: a systematic review, Journal of Chemotherapy, 32:5, 226-236, DOI: 10.1080/1120009X.2020.1785742 REFERENCE #3: Dé I, Rolston KV, Han XY. Clinical significance of Roseomonas species isolated from catheter and blood samples: analysis of 36 cases in patients with cancer. Clin Infect Dis. 2004 Jun 1;38(11):1579-84. doi: 10.1086/420824. Epub 2004 May 7. PMID: 15156446. DISCLOSURES: No relevant relationships by Aneeta Kumari, source=Web Response No relevant relationships by Kunal Nangrani, source=Web Response No relevant relationships by Jose Orsini, source=Web Response No relevant relationships by Evgeny Pinelis, source=Web Response No relevant relationships by Priya Raju, source=Web Response No relevant relationships by Keerthi Reddy Ramireddy, source=Web Response Speaker/Speaker's Bureau relationship with Allergan Please note: $20001 - $100000 by Joshua Rosenberg, source=Web Response, value=Honoraria No relevant relationships by Waqqas Tai, source=Web Response No relevant relationships by Viswanath Vasudevan, source=Web Response No relevant relationships by John Zeibeq, source=Web Response
ABSTRACT
TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Pseudallescheria boydii is a fungal organism isolated from agricultural soil and polluted water. Pseudallescheria boydii (P. boydii) can rarely cause an invasive disease which is primarily seen in organ transplant patients.1 It is unusual for it to cause a pulmonary infection.1 We present a case of a patient admitted with COVID-19 who was found to be infected with P. boydii. CASE PRESENTATION: A 58-year-old male with a history of heart failure, deep venous thrombosis, stroke was admitted for altered mental status in the setting of sepsis. On admission he complained of dry cough and weakness. Lab findings were significant for lymphopenia, elevated inflammatory makers, anemia, and thrombocytopenia. Chest imaging was suspicious for COVID pneumonia;however, initial COVID-19 PCR was negative. He was started on steroids for suspected COVID pneumonia. 72 hours later there was a significant decline in his mental and respiratory status, requiring mechanical ventilation. A bronchoscopy with bronchoalveolar lavage (BAL) was performed with worsening interstitial infiltrates on chest x-ray and high index of suspicion for a fungal cause of his pulmonary insult. COVID 19 PCR was repeated, which was later found to be positive. Neurological workup with CT head, lumbar puncture and EEG were negative. We were concerned about COVID-19 encephalopathy. He was maintained on steroids for concern of organizing pneumonia. Repeat chest imaging was impressive for cavitary lesion. BAL culture sent earlier was growing a mold prompting utilization of voriconazole for concern of invasive aspergillosis. Final cultures from BAL revealed P. boydii, and he was switched to isavuconazole due to QTc prolongation. Post treatment repeat cultures were negative. DISCUSSION: Pseudallescheria boydiis is commonly seen in immunocompromised patients such as solid organ transplants. Clinical and histological features of P. boydiis and invasive aspergillosis are similar and can be difficult to distinguish in clinical practice. Optimal treatment for this infection has yet to be elucidated due to multiple resistance patterns to drugs such as amphotericin B. Studies have shown that combinations or high dose antifungals have higher success rates for treatment, but there is no regimen that is universally agreed upon.2 Based on literature review this is the first case of P.boydii pneumonia in a COVID-19 patient successfully treated with isavuconazole. CONCLUSIONS: Incidence of P.boydii is rare even in the transplant population and extremely rare to cause pulmonary infection. Additional studies must be done to better understand the pathogenesis and treatment of P. boydii to improve patient outcomes due to its severe morbidity and mortality. Based upon literature review this is the first successfully treated case of P.boydii by Isavuconazole. REFERENCE #1: Bibashi, E et al. "Invasive infection caused by Pseudallescheria boydii in an immunocompetent patient." Hippokratia vol. 13,3 (2009): 184-6. REFERENCE #2: Lackner M, de Hoog GS, Verweij PE, Najafzadeh MJ, Curfs-Breuker I, Klaassen CH, Meis JF. Species-specific antifungal susceptibility patterns of Scedosporium and Pseudallescheria species. Antimicrob Agents Chemother. 2012 May;56(5):2635-42. doi: 10.1128/AAC.05910-11. Epub 2012 Jan 30. PMID: 22290955;PMCID: PMC3346635. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Joanna DeAngelis, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Tania Ghorban Azar, source=Web Response No relevant relationships by Ryan Kowalsky, source=Web Response No relevant relationships by Aneeta Kumari, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Steven Miller, source=Web Response No relevant relationships by Karina Muzykovsky, source=Web Response No relevant relationships by Kunal Nangrani, source=Web Response No relevant relationships by Jose O sini, source=Web Response No relevant relationships by Gaurav Parhar, source=Web Response No relevant relationships by Evgeny Pinelis, source=Web Response Speaker/Speaker's Bureau relationship with Allergan Please note: $20001 - $100000 by Joshua Rosenberg, source=Web Response, value=Honoraria No relevant relationships by jad sargi, source=Web Response No relevant relationships by Viswanath Vasudevan, source=Web Response No relevant relationships by Kiran Zaman, source=Web Response