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1.
J Infect Chemother ; 2022 Nov 12.
Article in English | MEDLINE | ID: covidwho-2105376

ABSTRACT

BACKGROUND: Aspergillus is one of the important pathogens that contribute to high mortality in patients with coronavirus disease 2019 (COVID-19) in intensive care units (ICUs). Although incidence rates of Aspergillus coinfection are high globally, a Japanese national survey reported a low incidence. This study aimed to describe the clinical characteristics of patients with COVID-19-associated pulmonary aspergillosis at our institute. METHODS: We identified patients with microbiologically confirmed COVID-19 on mechanical ventilation in the ICU. Of these patients, we identified patients in whom Aspergillus was cultured from the respiratory specimen. RESULTS: Of a total of 169 patients, seven had aspergillosis (4.1%), which included three patients, three patients, and one patient with possible, probable, and proven aspergillosis, respectively, according to the criteria of the European Confederation of Medical Mycology International Society. All patients received systemic steroid therapy. Two patients (one each with proven and probable aspergillosis) had tracheobronchitis diagnosed by bronchoscopy. All patients in whom Aspergillus was repeatedly isolated from samples died. The mortality rates for all cases and probable and proven cases were 57% (4/7) and 75% (3/4), respectively. CONCLUSIONS: The incidence rate of aspergillosis in patients with COVID-19 in the ICU was higher in our institute than that reported by a Japanese national survey (4.1% vs. 0.5%). Repeated detection of Aspergillus might suggest a true Aspergillus infection, such as chronic aspergillosis, rather than colonization. In patients with severe COVID-19 patients, it is important to always keep CAPA in mind.

2.
J Infect Chemother ; 2022 Nov 12.
Article in English | MEDLINE | ID: covidwho-2105375

ABSTRACT

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is being increasingly recognized as a severe complication that contributes to poor prognoses among patients with COVID-19. However, little is known regarding the clinical course of CAPA with hematological malignancies, especially after allogeneic hematopoietic stem cell transplantation (HSCT). A 29-year-old woman was diagnosed with proven CAPA with an Aspergillus fumigatus identified by cultures of bronchoalveolar lavage and lung biopsy four years after haploidentical HSCT for acute myelogenous leukemia. She had been taking oral prednisolone for bronchiolitis obliterans syndrome that developed after HSCT. Although prolonged RT-PCR positivity for SARS-CoV-2 (133 days after the onset of COVID-19) without shedding of viable virus was observed, the COVID-19 was treated with favipiravir, remdesivir, dexamethasone, and enoxaparin. However, the CAPA did not respond to combination therapy, which included triazole (voriconazole, itraconazole, posaconazole) and echinocandin (caspofungin, micafungin), even though the Aspergillus fumigatus isolate was found to be susceptible to these agents in vitro. Nevertheless, a total of 16 weeks of liposomal amphotericin B (L-AMB) therapy led to a favorable response, and the patient was discharged from the hospital on day 213. This case provided essential experience of CAPA treated with L-AMB in a recipient with chronic respiratory disease after HSCT.

3.
Journal of Pure and Applied Microbiology ; JOUR
Article in English | Web of Science | ID: covidwho-2100702

ABSTRACT

Coronavirus disease 2019 (COVID-19) infections can be related to vast spectrum of co-existent bacterial and fungal infections. A 49-year-old diabetic male was admitted with a history of fever, cough and breathlessness since 5 days. He developed persistent headache with right sided purulent nasal discharge. Relevant histo-pathological, biochemical, microbiological and imaging studies were performed which proved it to be a dual infection of Aspergillosis and Mucormycosis. We present one such case in a COVID-19 patient to highlight its unusual clinical features along with the diagnostic and therapeutic challenges.

5.
Radiología (English Edition) ; JOUR
Article in English | ScienceDirect | ID: covidwho-2086698

ABSTRACT

Fungal lung co-infections associated with COVID-19 may occur in severely ill patients or those with underlying co-morbidities, and immunosuppression. The most common invasive fungal infections are caused by aspergillosis, mucormycosis, pneumocystis, cryptococcus, and candida. Radiologists integrate the clinical disease features with the CT pattern-based approach and play a crucial role in identifying these co-infections in COVID-19 to assist clinicians to make a confident diagnosis, initiate treatment and prevent complications. Resumen Las coinfecciones pulmonares fúngicas asociadas a la COVID-19 pueden ocurrir en pacientes gravemente enfermos o con comorbilidades subyacentes e inmunosupresión. Las infecciones fúngicas invasivas más comunes son causadas por aspergilosis, mucormicosis, y las debidas a Pneumocystis, criptococo y cándida. Los radiólogos integran las características clínicas de la enfermedad con el enfoque basado en patrones de TAC y desempeñan un papel crucial en la identificación de estas coinfecciones en la COVID-19 para ayudar a los médicos a realizar un diagnóstico seguro, iniciar el tratamiento y prevenir complicaciones.

6.
Annals of Phytomedicine-an International Journal ; 10:41-55, 2021.
Article in English | Web of Science | ID: covidwho-2072559

ABSTRACT

Mucormycosis is a life-threatening infection. Mucormycetes causes a wide range of diseases, including pneumonia, rhinosinusitis, internal organ spread, gastrointestinal tract involvement, and skin and soft tissue infection. It infects predominantly with hematological malignancies, transplantation, immunocompromised, and diabetes mellitus patients. The most severe type of the disease is a disseminated disease, which is linked to significant immunosuppression. Currently, this disease is more prevalent in the COVID-19 pandemic because of erroneous steroid use and untreated diabetes. However, there is a scarcity of study and information on the COVID-19 and mucormycosis connection. According to the latest research, mucormycosis cases are rising in developed and developing nations, and only a few therapies are available. The exact burden of mucormycosis is unclear;however, it is likely to be greater than recorded instances due to mucormycosis epidemiological changes. As a result of the delay in identifying this severe illness, appropriate antifungal medications are delayed, resulting in significant morbidity and death. A few drugs are underclinical trials for their efficacy. Other obstacles to treat patients are lack of reliable diagnostic non-invasive tests. This review article draws the attention of its readers and clinicians towards the agents of mucormycosis and discuss the various cases to manage this fungal infection.

7.
Journal of the Scientific Society ; 49(2):106-113, 2022.
Article in English | Web of Science | ID: covidwho-2072002

ABSTRACT

The coronavirus disease 2019 pandemic (COVID-19) has led to considerable hike in hospitalizations for pneumonia with multiorgan disease requiring immediate hospital care, maintenance of oxygen saturation level, and severe cases requiring mechanical ventilation. This opens the window of opportunity to microscopic organisms such as different species of fungus including Candida, Aspergillus, Rhizopus, and Cryptococcus adding other fungi causing opportunistic invasive fungal infections (OIFIs), and other bacteria to cause concurrent infections in COVID-19-diseased patients which on occasion not promptly diagnosed and are mostly diagnosed after death, which get chance due to invasive procedures such as intubation and immunosuppressant drugs which mostly consists of corticosteroids, patient with diabetes mellitus or any other chronic disease causing immunosuppression, patient having a history of chronic obstructive airway disease, development of antibiotic resistance, and vulnerability of pulmonary tissues regarding developing colony for mycotic infections. In this review, we talk over the character of mycotic concurrent infections in aggravation of COVID-19 disease severity and focus on arising trends associated with fungal infections in coronavirus-diseased (COVID-19 diseased) cases. In addition, this review impart the view on the risky component for concurrent mycotic infections in COVID-19 diseased patients who are hospitalized and focuses the possible task of extended immunemodulatory treatments in managing concurrent mycotic infections, comprising COVID-19-associated pulmonary aspergillosis, COVID-19-associated Candidiasis, and mucormycosis. This article restates the demand for prompt detection regarding presumed COVID-19-related systematic mycosis in the health-care settings which could empower fast OIFI diagnosis, treatment, and lowers the mortality rate.

8.
Journal of Research in Medical and Dental Science ; 10(8):253-257, 2022.
Article in English | Web of Science | ID: covidwho-2067989

ABSTRACT

COVID-19 a global pandemic started in December 2019 and in these last year it has been linked to a range of bacterial, fungal, and viral infections. Mucormycosis sometimes known as black fungus is one of the rare but deadly angioinvaise fungal infection caused by group of fungi mucormycocetes which leads to upsurge of Mucormycosis in COVID-19 patients. Many states in India have declared mucormycosis as an epidemic due to its upsurge in numbers and higher fatality rate. Though mucorales can affect the any part of body but it has tissue tropism towards nasal sinuses, orbit, CNS, pulmonary, skin. Most common clinical presentation of fungi is infection of sinus with nasal blockage and discharge. Mucormycosis is a non-contagious fungal infection, more common in immune compromised patient. Acute inflammatory reactions in COVID-19, corticosteroids treatment and diabetes enfeeble the immunity and it makes the perfect storm for Mucormycosis. Diabetes that isn't well managed results in the acidosis a satisfactory environment for fungi to grow. An early diagnosis and management can decrease the fatality rate. Aim: The goal of this study is to provide a comprehensive overview of the literature concerning Mucormycosis aetiology, features, and management and how it can be prevented in COVID-19 (SARSCoV-2) patients. Conclusion: COVID-19, overuse of corticosteroid along with uncontrolled diabetes leads to an upsurge of mucormycosis. So an effort should be made to stringently monitor and keep the blood glucose level under control and judicious use of corticosteroid and antibiotics should be practiced in COVID-19 patients.

9.
American Journal of Transplantation ; 22(Supplement 3):645, 2022.
Article in English | EMBASE | ID: covidwho-2063410

ABSTRACT

Purpose: Invasive fungal infection (IFI) complicating Coronavirus disease of 2019 (COVID-19) has been increasingly recognized. IFI is a common opportunistic infection in solid organ transplant (SOT), but association with COVID-19 is unknown. Method(s): This was a retrospective study of all SOT recipients hospitalized with COVID-19 between March 2020 and Oct 2021. IFI was defined based on EORTC/ MSG criteria. Result(s): 107 SOT recipients were hospitalized due to COVID-19. 17 patients were excluded because they were on a systemic antifungal agent on admission. Median age was 62 yrs. 46% were female. 59% (53) were recipients of kidney, 17% (15) of lung, 11% (10) each of heart and liver, and 2% (10) of small bowel. 8% (7) of patients developed IFI within 90 days of COVID-19 (2 proven and 5 probable) (Table): 3 due to yeasts (2 bloodstream and 1 lung), and 4 pulmonary aspergillosis. Median time from COVID-19 diagnosis to IFI was 22 days (1d to 78d). Mechanical ventilation (P = 0.01) and augmented immunosuppression (p = 0.04) were risk factors for IFI;receipt of dexamethasone or IL-6 inhibitor were not risk factors. IFI associated with more prolonged hospital stay (median of 23 days (7-120d) vs 10d (1-80d), respectively). The 90-day mortality after COVID-19 diagnosis was 23% (21), higher for patients with IFI (57% vs 20%;p=0.04). By univariate analysis, the risk factors for death were: use of dexamethasone (p=0.011), IL-6 inhibitor (p=0.001), and IFI (p=0.049);SARS-CoV-2 monoclonal antibody (Mab) was protective (p=0.06). By multivariate analysis, receipt of IL-6 inhibitor (p=0.001) and IFI (p=0.009) were independent risk factors for death;Mab was protective (p=0.02). Overall, 18% (16) patients received systemic antifungals (AF);11% (9) received AFs without any IFI diagnosis and they all received anti-mold agents. Conclusion(s): The incidence of IFI complicating COVID-19 was 8%, and IFI was associated with a higher mortality. The association between receipt of IL-6 inhibitor and death among SOT patients is of concern. Risk and benefit of this agent along with it's side effect should be carefully evaluated in larger trials of SOT and other immunosuppressed COVID-19 patients. (Table Presented).

10.
Chest ; 162(4):A2565-A2566, 2022.
Article in English | EMBASE | ID: covidwho-2060965

ABSTRACT

SESSION TITLE: Rare Pulmonary Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Aspergillus is a group of opportunistic endemic fungal species that causes pathology within the respiratory tract and sinuses of individuals with predisposing factors, such as immunosuppression. While less frequently discussed, aspergillosis thyroiditis represents the most common fungal thyroiditis. We present a case of this condition that was misdiagnosed as amiodarone induced thyrotoxicosis. CASE PRESENTATION: A 54-year-old male was evaluated in outpatient pulmonary clinic after a chest CT revealed new upper lobe mass-like pleural based infiltrates with accompanying symptoms of dyspnea on exertion and fevers. His medical history was significant for orthotopic heart transplant 6 months ago due to a combination of non-ischemic cardiomyopathy with further decompensation from COVID-19 infection. After transplant, he was diagnosed with thyrotoxicosis secondary to amiodarone that was being treated with prednisone and methimazole. Given the concern for infection on imaging, he was admitted to the hospital and underwent urgent bronchoscopic evaluation. During the procedure, he was noted to have severe extrinsic tracheal compression. His neck imaging was consistent with a nodular goiter. The BAL revealed Aspergillosis fumigatus and he was subsequently treated with isavuconazium. Given the compression on the trachea and persistent dyspnea, the decision was to pursue total thyroidectomy. Surgery occurred 2 months after treatment was initiated for the Aspergillosis and with improvement on serial chest CTs. Pathologic examination of the thyroid tissue revealed extensive invasive aspergillus with abscesses involving both lobes. DISCUSSION: Aspergillus infection leading to disseminated disease typically occurs in individuals that have a compromised immune system such as seen in malignancy, solid organ transplant, chronic steroid use, and poorly controlled diabetes mellitus. Recently, it has been cited that up to 15% of hospitalized COVID-19 patients requiring intensive care develop aspergillus infection. After initial aspergillosis infection has been established, the thyroid gland is a site for dissemination due to its rich vascular supply. In addition, due to the angioinvasive properties of the pathogen, the fungus can breakdown tissue planes and easily travel from its site of origin. Thereby a primary infection in the respiratory tract can lead to dissemination to the neck structures due to its proximity. When thyroid invasion occurs, the common complaints are neck pain and swelling. Thyroid laboratory findings encompass the full spectrum including hyperthyroidism, hypothyroidism, and euthyroid. Given these non-specific findings, clinicians need to be conscious of this disease entity. CONCLUSIONS: In patients with immunocompromising conditions, findings of neck pain, swelling, and abnormal thyroid laboratory values should broaden the differential for clinicians to include aspergillosis thyroiditis. Reference #1: Alvi, Madiha M et al. "Aspergillus thyroiditis: a complication of respiratory tract infection in an immunocompromised patient.” Case reports in endocrinology vol. 2013 (2013): 741041. doi:10.1155/2013/741041 Reference #2: Marui, Suemi, et al. "Suppurative thyroiditis due to aspergillosis: a case report.” Journal of Medical Case Reports 8.1 (2014): 1-3. Reference #3: Kuehn, Bridget M. "Aspergillosis Is Common Among COVID-19 Patients in the ICU.” JAMA 326.16 (2021): 1573-1573. DISCLOSURES: No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Kristen Bussa Advisory Committee Member relationship with Boehringer Ingelheim Please note: 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting f e Advisory Committee Member relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note: 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note: 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee No relevant relationships by Haresh Mani No relevant relationships by Mary Beth Maydosz No relevant relationships by Alan Nyquist No relevant relationships by Anju Singhal No relevant relationships by Amy Thatcher

11.
Chest ; 162(4):A2190, 2022.
Article in English | EMBASE | ID: covidwho-2060909

ABSTRACT

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Eosinophilia is the most commonly reported adverse event following administration of the Pfizer/BioNTech vaccine, accounting for 237 of 372 events (63.7%). Eosinophilic pneumonia has been described noted in 3 of all reported cases. CASE PRESENTATION: We present the case of a 73 year-old male presented to his PCP with a 3 week history of nonproductive cough and wheezing. He completed a 2-shot series of BNT162b2 mRNA (Pfizer/BioNTech) COVID vaccine 1 week prior to symptom onset. He had no history of respiratory symptoms, smoking, sick contacts, recent travel, chemical or biological exposures. On presentation, he was afebrile, tachycardic and required 3LPM supplemental oxygen to maintain peripheral oxygen saturation (SpO2) above 94%. Laboratory findings noted leukocytosis (13,200/mL) and eosinophilia at 5% (Absolute Eosinophil Count (AEC): 580 cells/L). Respiratory viral panel, procalcitonin, ESR and D-dimer were negative. Chest CT scan was unremarkable. He was treated with azithromycin, prednisone and inhaled bronchodilators with improvement in hypoxia. 2 weeks later, he reported intermittent dyspnea during a pulmonary clinic visit. Pulmonary function testing was normal (FEV1/FVC: 76%;FVC: 3.67L (90% predicted);FEV1: 2.80L (88% predicted). IgE level was normal and eosinophilia had resolved. 6 months after initial symptom onset, the patient received his third BNT162b2 mRNA vaccine dose. 2 weeks after vaccination, he presented to the ED with severe dyspnea, wheezing and cough with yellow sputum. He also noted a new itchy, erythematous bilateral forearm rash and painless oral ulcers. On exam, he was afebrile, tachypneic with SpO2 of 93% on 4LPM supplemental oxygen and audibly wheezing with a prolonged expiratory phase. Laboratory studies noted elevated creatinine and leukocytosis (23,100/mL) with marked eosinophilia (29.5 %, AEC: 6814 cells/L). Chest CT scan revealed a 2 cm rounded ground-glass opacity in the right upper lobe. (Figure 1.) Further workup revealed a weakly positive antihistone antibody (1:4 titer). IgE, ANA, ANCA, SS-A/B, anti-CCP, and complement levels were normal. Intravenous methylprednisolone treatment was initiated with rapid improvement in dyspnea, eosinophilia and renal function. A transbronchial biopsy (Figure 2.) of the RUL lung lesion revealed organizing pneumonia with mixed inflammatory infiltrate. Bronchoalveolar lavage analysis revealed elevated WBC (432 cells/L) with neutrophilic predominance (85%). Patient was discharged home on a prednisone taper with resolution of symptoms. DISCUSSION: Subsequent allergy work up did not indicate any apparent etiology of hypereosinophilia. Testing for strongyloides, coccidiosis and aspergillosis were also negative. A final diagnosis of BNT162b2 mRNA vaccine related pulmonary eosinophilia was made. CONCLUSIONS: Additional study is warranted into eosinophilic disease associated with the BNT162b2 mRNA vaccine. Reference #1: 1. United States Department of Health and Human Services (DHHS), Public Health Service (PHS), Centers for Disease Control (CDC) / Food and Drug Administration (FDA), Vaccine Adverse Event Reporting System (VAERS) 1990 - 03/11/2022, CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/vaers.html on Mar 11, 2022 1:18:37 PM DISCLOSURES: No relevant relationships by Matthew Haltom No relevant relationships by Nikky Keer No relevant relationships by Thekrayat Khader No relevant relationships by Muthiah Muthiah

12.
Chest ; 162(4):A1776, 2022.
Article in English | EMBASE | ID: covidwho-2060859

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The most reported fungal infections in patients with COVID-19 include aspergillosis, invasive candidiasis, and mucormycosis. We hereby present a case of a male who developed acute pulmonary histoplasmosis (APH) after COVID-19 infection. CASE PRESENTATION: 51-year-old male with PMHx of COVID-19 infection 3 weeks ago presenting with worsening shortness of breath. Patient had a complicated hospital course with COVID-19 treated with high doses of methylprednisolone. Patient was local to Arizona and lived on a ranch with livestock. CT chest suggestive of multilobar pneumonia and bilateral pleural effusions (Image 1). Coccidiomycosis serology came back negative. Urinary Histoplasma galactomannan antigen came back positive. The diagnosis of APH after COVID-19 infection was established. Patient was started on voriconazole. His symptoms significantly improved. Patient was discharged to skilled nursing facility with outpatient infectious disease follow-up. DISCUSSION: The current literature on APH in the setting of COVID-19 infection is limited. The few proposed mechanisms are: 1. Liberal use of high dose steroids in COVID-19 leading to reactivation of latent H. Capsulatum. 2. Systemic inflammation in COVID-19 causes interstitial lung damage permitting conidia to proliferate leading to acute infection. The Histoplasma urine antigen test is highly sensitive in the diagnosis of APH, especially in immunocompromised patients like our patient. With this case we would like to increase awareness of the possibility of rare fungal infections like APH in patients with COVID-19, as timely diagnosis and appropriate management can lead to improved outcomes. CONCLUSIONS: Rare fungal infections following COVID-19 have been documented and timely diagnosis and management are imperative to improve patient outcomes. Reference #1: Macedo, Priscila M, et al. APH following COVID-19. Case Report J.Fungi 2021 DISCLOSURES: No relevant relationships by Ali Raja no disclosure on file for Yamin Saddouk;No relevant relationships by Parita Soni No relevant relationships by Lyndie Wilkins Parker

13.
Chest ; 162(4):A1764, 2022.
Article in English | EMBASE | ID: covidwho-2060857

ABSTRACT

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: COVID-19 Associated Pulmonary Aspergillosis (CAPA) is a subset of invasive pulmonary aspergillosis occurring in patients actively infected with or recovering from COVID-19. It has mostly been described in immunocompromised or severely ill patients requiring invasive mechanical ventilation[1-6]. The authors report a case of CAPA infection in an ambulatory and immunocompetent patient with prior lung resection. CASE PRESENTATION: A 20-year-old male presented to a Comprehensive Cancer Center for fever and hemoptysis. He carried a diagnosis of metastatic germ cell tumor to his lungs, status post left upper-lobe wedge resection. He had completed bleomycin, etoposide, and cisplatin (BEP) chemotherapy one year earlier. He was recently diagnosed with COVID-19 one month prior to admission and treated as an outpatient with monoclonal antibodies. He reported ongoing cough productive of clear sputum since his diagnosis, which had worsened over the previous two days and was now blood-tinged. He had been afebrile for weeks before noting new fevers over the same period. Physical examination was notable for fever to 38.6°C and lungs clear to auscultation. His labs were significant for a WBC of 14.5 K/mcl (82.5% neutrophils), Cr 2.1 mg/dL (baseline 1.5 mg/dL), and normal platelets and coagulation studies. Serum Aspergillus galactomannan was normal. Repeat SARS-CoV-2 PCR was negative. Chest x-ray was unchanged. V/Q scan showed no evidence of pulmonary embolism. Non-contrast CT chest performed on hospital day #4 revealed a partial opacification and increased wall thickness of patient's largest left upper lobe surgical cavitation (see Image 1). A bronchoscopy was performed day #6, with bronchoalveolar lavage (BAL) galactomannan >5.56 (normal <0.5)7;fungal culture was significant for septate hyphae. He was started on voriconazole with improvement in his symptoms and discharged day #9. DISCUSSION: Immunocompromised patients with prolonged neutropenia, solid-organ or stem cell transplants, and patients with advanced AIDS are at highest risk of contracting PA[8-9]. ARDS secondary to viral pneumonia is also a common precipitant in immunocompetent patients[1-6,10,11]. The exact mechanism of this association remains unknown, but it is postulated to occur due to multiple factors, including host immune dysregulation[1,2], widespread exposure to corticosteroids[1,2], concomitant lung disease[1], and viral-induced lymphopenia[2]. We report a case of an immunocompetent patient with prior lung resection recovering from COVID-19 who experienced a secondary worsening of symptoms ultimately found to have CAPA to further highlight the link between these conditions. CONCLUSIONS: While many of CAPA case reports describe patients with typical risk profiles for CAPA, this case suggests that clinicians should consider structural lung disease alone in an otherwise immunocompetent, ambulatory individual to be a potential risk factor. Reference #1: See Image 2 for full list of references. DISCLOSURES: No relevant relationships by Raphael Rabinowitz No relevant relationships by Matthew Velez

14.
Chest ; 162(4):A1365, 2022.
Article in English | EMBASE | ID: covidwho-2060810

ABSTRACT

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Non-traumatic bronchial injury (NTBI) incidence is not well described but traumatic Tracheobronchial injury (TBI) incidence is 3% with a 70 -100% mortality3. Causes identified for NTBI are associated with vascular supply compromise2. TBI presents with dyspnea, subcutaneous emphysema, pneumothorax, and/or pneumomediastinum4. It can be missed up to 68% of the cases. Bronchoscopy is the study of choice and management is based on studies from traumatic TBI2, 3. This report describes a unique case of NTBI in a patient with recent COVID-19 infection, uncontrolled diabetes, and invasive pseudomembranous Aspergillosis presenting with a left bronchial tear (LBT). CASE PRESENTATION: A 41-year-old with uncontrolled diabetes and prior admission for COVID-19 infection and diabetic ketoacidosis (DKA) managed with steroids and antibiotics. Presenting cough, fever, intermittent chest pain, and palpitations. He was afebrile, tachycardic, and hypoxemic requiring supplemental oxygen. Chest examination revealed crackles and decreased breath sounds at the lung bases. Laboratory studies showed leukocytosis, hyperglycemia, and anion gap metabolic acidosis. SARS-CoV-2 PCR was negative. CT chest revealed an anterior wall defect of the left bronchus with a pneumomediastinum. Bronchoscopy showed pseudomembranous necrotic debris of the tracheobronchial tree and left main bronchus tear with visible rhythm-beating pericardium surrounding the heart. Cytopathological findings of the bronchoalveolar fluid were consistent with Aspergillus species (AS). DISCUSSION: NTBI are rare with a high mortality3. NTBI due to AS has been described in post-lung transplant patients. AS produces endotoxins and proteases that damage the epithelium, leading to erosion of surrounding structures2,3. Since COVID-19, invasive fungal infections (IFI) have risen due to lung damage and immunologic deficits associated with the virus or immunomodulatory therapy6. Our patient risk factors for IFI included recent COVID-19 infection, steroid use, and uncontrolled diabetes. This unholy trinity has coexisted during COVID-19 self-potentiating the problem of immune dysregulation leading to IFI and tissue necrosis7. This may cause NTBI as in our case presenting with LBT. Despite antimicrobial therapy, he died due to massive hemoptysis from erosion of the pericardium or angio-invasion of surrounding vessels. CONCLUSIONS: Rarity of NTBI constitutes a challenge for early diagnosis and management. Identifying predisposing risk factors, a high clinical suspicion, and appropriate diagnostic workup is of vital importance. During the COVID-19 pandemic, IFI have an increased incidence associated with high mortality rates. Despite more cases being described there are still knowledge gaps related to prevention, diagnosis, and management. Reference #1: Jones D, Nelson A, Ma OJ. Pulmonary Trauma. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill Education;2016. accessmedicine.mhmedical.com/content.aspx?aid=1121516674 Reference #2: Aerni MR, Parambil JG, Allen MS, Utz JP. Nontraumatic Disruption of the Fibrocartilaginous Trachea: Causes and Clinical Outcomes. Chest. 2006;130(4):1143-1149. doi:https://doi.org/10.1016/S0012-3692(15)51151-3 Reference #3: AK AK, Anjum F. Tracheobronchial Tear. StatPearls Publishing;2022. Accessed March 13, 2022. https://www.ncbi.nlm.nih.gov/books/NBK560900/ DISCLOSURES: No relevant relationships by Jorge Alejandro Bernal No relevant relationships by Adriana Betancourth No relevant relationships by Reham Majzoub No relevant relationships by Juan Pablo Sarmiento Cano

15.
Chest ; 162(4):A954, 2022.
Article in English | EMBASE | ID: covidwho-2060740

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: SARS-CoV-2 pandemic has shown rare and varied presentations of known pathology and infectious processes. We discuss the case of a patient developing bronchial tree ulcerations in the backdrop of SARS-CoV-2 and superimposed infections. CASE PRESENTATION: This was a 59-year-old male with past medical history of B-cell lymphoma, diagnosed with SARS-CoV-2 infection. He was admitted with shortness of breath and increased oxygen requirement. In brief, his hospital course included bilevel positive airway pressure noninvasive ventilation along with steroids, baricitinib and therapeutic anticoagulation. His clinical status worsened to severe acute respiratory distress syndrome and he progressed to mechanical ventilation. While on the ventilator he was treated with paralysis and proning. Due to worsening hypoxia and secretions, he underwent bronchoscopy showing copious thick mucoid white patches and secretions in trachea extending to the right and left mainstem bronchi and extensive mucus plugging. Baricitinib was discontinued and he was placed on empiric micafungin, broad spectrum antibiotics while results were pending. He required repeat bronchoscopy for therapeutic suctioning of recurrent copious thick white secretions with mucus plugging. Cultures resulted as aspergillus fumigatus and micafungin was switched to voriconazole. Two weeks later, in an ongoing prolonged intubated state, he developed cuff leak requiring tube exchange and repeat bronchoscopy, which showed development of multiple bilateral ulcerations with central necrosis and sloughing in the right and left bronchial tree. Repeat lab evaluation of the bronchoscopy samples now resulted in growth of nocardia along with aspergillus species. DISCUSSION: Ulceration of bronchial tree may be seen in malignant lesions, autoimmune conditions, poisoning or toxicology cases. Occurrence of pulmonary ulcerations are rare in infectious cases as sequalae in the SARS-CoV-2 pandemic. Patient's immunocompromised state, with history of B-cell lymphoma, prolonged steroid and JAK inhibitor administration, predisposes to higher propensity of infections. Bronchial tree ulceration also leads to suspicion of viral infections such as herpes, varicella which were found to be negative from bronchial samples. It remains difficult to ascertain if the prolonged aspergillus infection led to progression of white plaques into ulcerations, or the newly diagnosed secondary infection of nocardia caused bronchial tree ulcers. Historically, aspergillus has been associated with blackened ulcerations as opposed to the findings here. Also, patient had been receiving treatment with voriconazole for 2 weeks prior to diagnosis of ulcers, therefore raising suspicion for a rare nocardial etiology as well. CONCLUSIONS: Prolonged intubation in immunocompromised patients may lead to superimposed nocardial and aspergillus infections causing airway ulcerations and increased mortality. Reference #1: Judson MA, Sahn SA. Endobronchial lesions in HIV-infected individuals. Chest. 1994;105(5):1314-1323. doi:10.1378/chest.105.5.1314 Reference #2: Abdel-Rahman N, Izhakian S, Wasser WG, Fruchter O, Kramer MR. Endobronchial Enigma: A Clinically Rare Presentation of Nocardia beijingensis in an Immunocompetent Patient [published correction appears in Case Rep Pulmonol. 2016;2016:1950463]. Case Rep Pulmonol. 2015;2015:970548. doi:10.1155/2015/970548 DISCLOSURES: No relevant relationships by Habiba Hussain No relevant relationships by Matthew Sehring

16.
Chest ; 162(4):A692-A693, 2022.
Article in English | EMBASE | ID: covidwho-2060669

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Coronavirus Disease 2019 (COVID-19) infection ranges from asymptomatic to severe disease as defined by WHO. Emerging fungal infections such as mucormycosis and aspergillosis have been described in critically ill patients, most notably in India, when treated with steroids due to severe COVID-19 [1]. We present a unique case of an atypical presentation of mucormycosis in a non-severe COVID-19 patient not treated with corticosteroids. CASE PRESENTATION: A 19-year-old male with type 1 diabetes mellitus presented to the emergency room for evaluation of shortness of breath, nausea and fatigue. History was significant for insulin noncompliance with home blood glucose in the 300s and a positive COVID-19 test one day prior to arrival. Initial vitals positive for tachycardia, tachypnea and hypertension while on room air. Labs showed leukocytosis 14,000 cells/uL, bicarbonate 7.2 mmol/L, anion gap 24.8, glucose 428 mg/dL, beta-hydroxybutyrate 58 mg/dL and nucleic acid amplification COVID-19 positive. Physical exam showed left eyelid and facial swelling, nasal congestion without sinus tenderness or other deformity, and kussmaul breathing pattern. CT face confirmed left periorbital cellulitis. Transfer to tertiary center for Ophthalmology evaluation was attempted but refused due to capacity. He was started on diabetic ketoacidosis treatment as well as broad spectrum antibiotics with the assistance of Infectious Disease, however COVID-19 treatments were held due to mild illness. Despite these interventions, he became stuporous and amphotericin was started. MR Brain showed findings suggestive of cavernous sinus thrombosis, acute ischemia and local mass effect. ENT then performed an endoscopic antrostomy with ethmoidectomy and biopsies were taken. Pathology resulted as invasive fungal sinusitis with 90° branching hyphae confirming mucormycosis and a lumbar drain was placed with intrathecal amphotericin started for concern of mucormycosis meningitis. The patient was ultimately transferred to a tertiary care center where he expired. DISCUSSION: Mucormycosis, an angioinvasive fungal infection affecting the immunocompromised and diabetics, is rare but deadly. The estimated prevalence in the United States is 0.16 per 10,000 hospital discharges [2] and bears a mortality rate of 46%. Recent systematic reviews report 275 cases of COVID associated mucormycosis with 233 in India [1] with 76.3% receiving corticosteroids prior to diagnosis [3], likely contributing to an immunocompromised state. Our case demonstrates that despite not receiving corticosteroids, even those with mild COVID-19 are at risk for this disease. CONCLUSIONS: Patients with diabetes, immunocompromised states, and now COVID-19, presenting with orbital symptoms warrant consideration of mucormycosis. Prompt management of the underlying condition, IV amphotericin, and possible debridement may increase survival. Reference #1: John TM, Jacob CN, Kontoyiannis DP. When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis. J Fungi (Basel). 2021 Apr 15;7(4):298. doi: 10.3390/jof7040298. PMID: 33920755;PMCID: PMC8071133. Reference #2: Kontoyiannis DP, Yang H, Song J, et al. Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study. BMC Infect Dis. 2016;16(1):730. Published 2016 Dec 1. doi:10.1186/s12879-016-2023-z Reference #3: Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021 Jul-Aug;15(4):102146. doi: 10.1016/j.dsx.2021.05.019. Epub 2021 May 21. PMID: 34192610;PMCID: PMC8137376 DISCLOSURES: No relevant relationships by james abraham No relevant relationships by christian ALMANZAR ZORRILLA No relevant relationships by Grace Johnson No relevant relationships by Thanuja Neerukonda No relevant relationships by Blake Spain No relevant re ationships by Michael Su No relevant relationships by Steven Tran No relevant relationships by Margarita Vanegas No relevant relationships by Alexandra Witt

17.
Chest ; 162(4):A642, 2022.
Article in English | EMBASE | ID: covidwho-2060656

ABSTRACT

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Since the start of the COVID-19 pandemic, COVID-19 Associated Pulmonary Aspergillosis (CAPA) has been on the rise. This superinfection, if not properly identified and treated, has shown to increase mortality up to 67% in COVID-19 patients. We are presenting a late presentation of CAPA after 4-month of COVID-19 infection and treated successfully. CASE PRESENTATION: A 57-year-old female patient with past medical history type 2 diabetes mellitus, hypertension and cardiomyopathy in addition to COVID-19 pneumonia treated for months ago with azithromycin, Bamlanivimab/Etesevimab, and Dexamethasone who presents to the hospital with massive hemoptysis and shortness of breath requiring intubation and mechanical ventilation. There was no reported history of recent travel, smoking, alcohol, or illicit drug use. Physical exam showed diminished lung sounds at the right lower lobe. Her labs showed mild leukocytosis, lactic acidosis and negative COVID-19 PCR. CT scan showed dense consolidation on right lower lobe consistent with lobar pneumonia and centrilobular ground glass opacities in the right upper lobe. Bronchoscopy showed complete obstruction of right bronchus intermedius and minimal blood clots in LLL. BAL respiratory culture, fungal smear, acid fast bacilli were non-diagnostic and negative for malignancy. Patient continued to have hemoptysis and bronchoscopy was repeated with negative cytology and cultures. The patient continued to have hemoptysis and she was transferred to tertiary center were bronchoscopy was repeated and confirmed right bronchus intermedius stenosis, blood clots, and suspicious right mainstem nodules with mucosal lesion. Biopsy results from bronchoscopy came back positive for the morphologic features of Aspergillus species. The patient was started on voriconazole with significant improvement in her symptoms. DISCUSSION: The recent literature of COVID-19 suggest association between COVID infection and invasive pulmonary Aspergillosis. COVID-19 virus causes damage in the airway epithelium and enable aspergillus to invade the pulmonary tract leading to serious infections with Aspergillus. It has also been known that Aspergillus infections are associated with diabetes mellitus and immune suppression which can be precipitated by steroid use and other treatments for COVID-19 infection like IL-6 inhibitors. Here in our patient with help of tissue biopsy we diagnosed CAPA, started treatment early and treated successfully. CONCLUSIONS: CAPA can be difficult to diagnose and needs high index of suspicion in the appropriate clinical scenario when dealing with post COVID respiratory complaints like hemoptysis. Bronchoalveolar lavage alone without tissue biopsy might miss the diagnosis in the context of invasive aspergillosis like the scenario we observed in our case. Doing tissue biopsy through bronchoscopy might add more clinical benefit when Aspergillus infections are suspected. Reference #1: Chih-Cheng Lai, Weng-Liang Yu, COVID-19 associated with pulmonary aspergillosis: A literature review, https://doi.org/10.1016/j.jmii.2020.09.004 DISCLOSURES: No relevant relationships by Haytham Adada No relevant relationships by Mahmoud Amarna No relevant relationships by Rishika Bajaj No relevant relationships by Camelia Chirculescu No relevant relationships by Sonia Dogra No relevant relationships by Azad Patel

18.
Chest ; 162(4):A623-A624, 2022.
Article in English | EMBASE | ID: covidwho-2060649

ABSTRACT

SESSION TITLE: Unusual Pneumonias SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Invasive pulmonary aspergillosis (IPA) commonly occurs in the setting of immunosuppression. Underlying lung disease is a well-known risk factor for IPA;however, interstitial lung disease (ILD) has not been recognized as a risk factor for IPA[1]. CASE PRESENTATION: A 40-year-old male with a history of a failed kidney transplant now on hemodialysis (HD), Juvenile Rheumatoid Arthritis, Mixed Connective Tissue Disease, Aspergilloma led to right lower lobectomy a year ago, COVID-19 infection three months ago, chronic lung disease (CLD) thought to be due to Nonspecific interstitial pneumonia (NSIP) presented with dyspnea. He had several hospitalizations for respiratory failure needing intubation or NIPPV, broad-spectrum antibiotics, steroids, and HD with improved respiratory status, eventually discharged. Bronchoalveolar lavage fluid culture grew aspergillus terreus but was negative for Pneumocystis (PCP), bacteria, acid-fast bacilli, and Nocardia. The transbronchial biopsies showed mixed inflammatory type and fungal forms in one specimen. Additionally, the initially negative galactomannan converted into a serial rise in galactomannan (>3.75 Index) along with a rise in beta d-glucan (>500 pg/ml). Unfortunately, he had gaps in antifungals and was readmitted similarly. Micafungin was added for dual fungal coverage and was planned for surgical lung biopsy to characterize ILD further once his respiratory status allows. DISCUSSION: He has multiple risk factors for developing IPA, such as high-dose steroids for ILD and recent COVID infection. Initially, respiratory failure was thought to be due to exacerbation of ILD, and suspicion for IPA was low because of lack of neutropenia, negative fungal biomarkers, lack of classic findings on lung imaging, and in-hospital clinical improvement with steroids. However, the eventual course of recurrent respiratory failure while on high-dose steroids, along with gaps in antifungal therapy and continued growth of Aspergillus, made IPA the most likely diagnosis. For IPA, the mainstay of treatment is both adequate antifungal therapy and reduction in immunosuppression to the extent possible[2];however, it is unclear if his underlying ILD can tolerate steroid taper. He will need a lung transplant after adequately treating IPA. CONCLUSIONS: There are no current guidelines on simultaneously treating IPA and NSIP. It is challenging to balance reduction in immunosuppression as tolerated for ILD and concurrently maintain antifungal therapy. During this patient's hospitalization, there have been considerations of using a steroid-sparing agent for his suspected NSIP, however, in the setting of active infection, its benefit is debatable.[3] Reference #1: Matsuyama H, Miyoshi S, Sugino K, et al. Fatal Invasive Pulmonary Aspergillosis Associated with Nonspecific Interstitial Pneumonia: An Autopsy Case Report. Intern Med. 2018;57(24):3619-3624. doi:10.2169/internalmedicine.1144-18 Reference #2: Thomas F. Patterson, George R. Thompson, III, David W. Denning, Jay A. Fishman, Susan Hadley, Raoul Herbrecht, Dimitrios P. Kontoyiannis, Kieren A. Marr, Vicki A. Morrison, M. Hong Nguyen, Brahm H. Segal, William J. Steinbach, David A. Stevens, Thomas J. Walsh, John R. Wingard, Jo-Anne H. Young, John E. Bennett, Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 63, Issue 4, 15 August 2016, Pages e1–e60, https://doi.org/10.1093/cid/ciw326 Reference #3: Mezger, M., Wozniok, I., Blockhaus, C., Kurzai, O., Hebart, H., Einsele, H., & Loeffler, J. (2008). Impact of mycophenolic acid on the functionality of human polymorphonuclear neutrophils and dendritic cells during interaction with Aspergillus fumigatus. Antimicrobial agents and chemotherapy, 52(7), 2644–2646. https://doi.org/10.1128/AAC.01618-07 DISCLOSURES: No relevant relationships by Nasir Alhamdan No relevant relati nships by Parth Jamindar No relevant relationships by Harshitha Mergey Devender No relevant relationships by Abira Usman No relevant relationships by Vishruth Vyata

19.
Chest ; 162(4):A612-A613, 2022.
Article in English | EMBASE | ID: covidwho-2060647

ABSTRACT

SESSION TITLE: TB and TB-Involved Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary Aspergillus infection has a wide array of manifestations. Chronic Pulmonary Aspergillosis is an uncommon progressive respiratory disease, with the Subacute Invasive Pulmonary Aspergillosis form, one of the most challenging to manage. Typically it presents with rapidly progressive infection (of less than 3 months) in mild to moderately immunocompromised patients with underlying structural lung disease. We herein report the case of a 69-year old female with post-tuberculous cavity with disease progression, in approximately 6 weeks, associated with Aspergillus infection. CASE PRESENTATION: Patient is a 69-year old African American female, never smoker, with known history of Type 2 Diabetes Mellitus and previously treated mycobacterium tuberculosis with residual small right upper lobe cavity (measuring approximately 35 x 40 mm). She was being followed in our outpatient thoracic oncology clinic with serial imaging for surveillance, CT Chest initially every 3 - 6 months then annually thereafter with PET scan as clinically indicated. The cavity remained relatively unchanged for approximately 5 years. In October 2021, her CT Chest had revealed a stable cavity, even despite SARS-CoV-2 Pneumonia infection the previous year. The following month she was admitted to an outside hospital for hyperglycemia with notable significant increase in size of the right upper lobe cavity to 69 x 72 mm with surrounding nodularity. She completed a course of antibiotics and was seen in our clinic 3 months post discharge with a repeat CT Chest which now revealed a mass like area of consolidation with large area of lucency and superimposed fungus ball (now measuring 80 mm x 70mm). She underwent Electromagnetic Navigational Bronchoscopy with transbronchial biopsy and right upper lobe bronchoalveolar lavage. BAL culture identified Aspergillus niger, with no other pathogens (including acid fast bacilli isolated) or malignant cells observed. Biopsy revealed marked mixed inflammation and fungal hyphae. Patient is currently undergoing long-term oral antifungal therapy with plan for close surgical follow-up. DISCUSSION: The diagnosis of Chronic Pulmonary Aspergillosis requires a combination of clinical, radiological and histopathological characteristics present for atleast 3 months for diagnosis. This includes the presence of one or more cavities on thoracic imaging, evidence of aspergillus infection or an immunological response to aspergillus as well as excluding alternative diagnoses. Advances in diagnostic tools have improved early diagnosis and subsequent management as noted in our case. Surgical resection is recommended for simple aspergilloma, however rapidly progressive disease processes are recommended to be managed as invasive aspergillosis. CONCLUSIONS: Post-tuberculosis chronic pulmonary aspergillosis is an emerging disease with significant associated morbidity and likely health burden. Reference #1: Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management David W. Denning, Jacques Cadranel, Catherine Beigelman-Aubry, Florence Ader, Arunaloke Chakrabarti, Stijn Blot, Andrew J. Ullmann, George Dimopoulos, Christoph Lange European Respiratory Journal Jan 2016, 47 (1) 45-68;DOI: 10.1183/13993003.00583-2015 Reference #2: Bongomin F. Post-tuberculosis chronic pulmonary aspergillosis: An emerging public health concern. PLoS Pathog. 2020;16(8):e1008742. Published 2020 Aug 20. doi:10.1371/journal.ppat.1008742 DISCLOSURES: No relevant relationships by Omotooke Babalola No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Sulaiman Tijani

20.
Chest ; 162(4):A585-A586, 2022.
Article in English | EMBASE | ID: covidwho-2060638

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: COVID-19 patients requiring admission to an ICU have a higher risk of invasive pulmonary aspergillosis (IPA) with a reported incidence of 19.6%-33.3%. CASE PRESENTATION: A 63-year-old male presented with progressively worsening dyspnea for one week. He has a past medical history of atrial fibrillation, hypertension, and obesity. He was tested positive for COVID about two weeks prior. He did receive a single dose of Moderna vaccine. Initial chest x-ray(CXR) showed diffuse ground-glass opacities. He was initiated on Remdesivir and decadron, and later received a dose of tocilizumab. He was intubated on hospital day 3 for worsened hypoxemia. Repeat CXR suggested some improvement but a new left lower lobe airspace haziness. He also had new-onset leukocytosis with elevated procalcitonin level. He was started on cefepime for concern of superimposed hospital-acquired pneumonia. A second dose of tocilizumab was administered. No clinical improvement was seen, and additional workups were obtained. Serial CXRs revealed increasing diffuse airspace opacities concerning for ARDS. Tracheal aspirate culture grew coagulase-negative staphylococcus and Aspergillosis Fumigatus. Cefepime was changed to vancomycin, and voriconazole and caspofungin were added. Unfortunately, the patient's respiratory status worsened with increasing ventilation requirement. He also developed septic shock and acute renal failure requiring CVVH. He became even more hypotensive after CVVH initiation, and multiple vasopressors were required to maintain his hemodynamics. Unfortunately, he continued to deteriorate and he also developed profound respiratory acidosis. He died shortly afterwards after family decided to withdraw care. DISCUSSION: In this case, in addition to superimposed bacterial pneumonia, pulmonary aspergillosis likely also contributed to his clinical deterioration. The mechanism by which fungal infections develop in COVID-19 infection is not well-understood. Severe COVID-related immune dysregulation, ARDS, and high-dose steroids use are potential culprits for the increased risk of IPA. Tocilizumab, an IL-6 receptor monoclonal antibody used in patients with severe COVID-19 infection, may also predispose the patient to IPA according to post-marketing data. The mortality rate from current case reports is as high as 64.7%. Diagnosis and treatment in such a scenario remain a challenge. Sputum culture, serum Beta-galactomannan, Beta-D glucan, and aspergillosis PCR have low sensitivity. Tissue biopsy and CT scan in critically ill patients are often not feasible. Voriconazole is usually considered the first-line treatment in IPA. CYP3A4-mediated drug interactions between azoles and antiviral agents require further investigation. CONCLUSIONS: Clinicians should be aware that severe COVID-19 patients are at higher risk of IPA. The prognosis is poor. Early detection and treatment in clinically deteriorated patients are warranted. Reference #1: Borman, A.M., Palmer, M.D., Fraser, M., Patterson, Z., Mann, C., Oliver, D., Linton, C.J., Gough, M., Brown, P., Dzietczyk, A. and Hedley, M., 2020. COVID-19-associated invasive aspergillosis: data from the UK National Mycology Reference Laboratory. Journal of clinical microbiology, 59(1), pp.e02136-20. Reference #2: Lai CC, Yu WL. COVID-19 associated with pulmonary aspergillosis: A literature review. J Microbiol Immunol Infect. 2021;54(1):46-53. doi:10.1016/j.jmii.2020.09.004 Reference #3: Thompson Iii GR, Cornely OA, Pappas PG, et al. Invasive Aspergillosis as an Under-recognized Superinfection in COVID-19. Open Forum Infect Dis. 2020;7(7):ofaa242. Published 2020 Jun 19. doi:10.1093/ofid/ofaa242 DISCLOSURES: No relevant relationships by Jason Chang No relevant relationships by Jason Chang No relevant relationships by kaiqing Lin No relevant relationships by Guangchen Zou

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