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1.
NeuroQuantology ; 20(9):5579-5590, 2022.
Article in English | EMBASE | ID: covidwho-2067299

ABSTRACT

The emergence of SARS-CoV-2 has increased mucormycosis cases, which was perceived to be a rare infection caused by belligerent fungi belonging to order Mucorales. It is also called the black fungus and is exhibited as one of the seven variants such as rhino-cerebral, cutaneous, pulmonary, renal, gastrointestinal, disseminated or miscellaneous, leading to the debilitation of systemic wellness often associated with a reduction in functional efficiency and characterized by organ failure due to necrosis necessitating early diagnosis and timely treatment. Hence, to sustain the quality of life during the pandemic, a better understanding of mucormycosis is the need of the hour for efficient management to overcome global crises. This review was carried out on existing literature over three decades involving data in India as well as its global comparison, especially in terms of incidence and prevalence for enabling a scientifically evidence-based comprehensive analysis so that appropriate modalities could be adopted in individuals with immunocompromised conditions to safeguard them from contracting as they are more susceptible to having high-risk exposure. Copyright © 2022, Anka Publishers. All rights reserved.

2.
Archives of Clinical Infectious Diseases ; 17(4), 2022.
Article in English | EMBASE | ID: covidwho-2067097

ABSTRACT

Context: The current pandemic of COVID-19 affected all people of the world. Evidence Acquisition: Most complications of SARS-CoV-2 are causally related to severe pneumonia due to host immune response in the form of a cytokine storm. The other causes of an increased mortality rate among COVID-19 patients are secondary infections. Results: Mucormycosis is a life-threatening infection that gained much attention in the ongoing COVID-19 pandemic. A rise in the frequency of COVID-19-associated mucormycosis (CAM) occurred in 2020 and 2021. Overall, mortality of CAM has been reported as 54%-75%. Conclusions: Although awareness of the disease has increased among treating physicians, disease-associated morbidity and mortality are still high. The guideline is intended to serve as a reference to prevent mucormycosis in COVID-19 patients and help health-care providers choose diagnostic and treatment methods for the best management of CAM cases.

3.
Anti-Infective Agents ; 20(4) (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2065291

ABSTRACT

Mucormycosis is the most emerging angioinvasive fungal infection of filamentous fungi of the Zygomycetes class, which, when neglected, causes severe disseminated infection along with significant chances of morbidity and mortality. The diagnosis and treatment remain challenging for the doctors. It has been observed that people who have been suffering from different diseases, such as hematological malignancies and uncontrolled diabetes, or who have gone through different surgeries, such as hemato-poietic stem cell transplant, and solid transplantation, are the most affected ones. On the other hand, people who have recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) typically show the symptoms of mucormycosis after 1-2 weeks of successful recovery. Standard treatment of mu-cormycosis is traditionally considered an amphotericin B intravenous (IV) drug as initial therapy, alt-hough posaconazole and isavuconazole are also used. The core objective of the review is to typically focus on the area of the sudden cause of mucormycosis in the patients who have already recovered from SARS-CoV-2. Copyright © 2022 Bentham Science Publishers.

4.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P150, 2022.
Article in English | EMBASE | ID: covidwho-2064481

ABSTRACT

Introduction: The pandemic of COVID-19 in association with mucormycosis would be a deadly fungal infection with high level of mortality and morbidity. Our aim is to evaluate the surgical outcome of patients with rhino-orbito-cerebral mucormycosis to suggest better management strategies. Method(s): A total of 62 cases of COVID-19-associated rhino-orbito-cerebral mucormycosis were admitted to the ear, nose, throat department in Mashhad, Iran, from August 1 to October 15, 2021. All data were analyzed using SPSS version 27.0. Descriptive analysis was used for demographic and clinical characteristics. Result(s): Main predisposing conditions were diabetes mellitus (90%) followed by hypertension (41%). Main symptoms were headache (75%), periorbital or retro-orbital pain (61%), visual loss (45%), and facial numbness (41%). Mucosal and ocular findings showed necrosis (67%), blindness (n=35), ptosis (n=31), proptosis (n=27), ophthalmoplegia (n=25), and chemosis (n=20). Neurologic loss of consciousness (19%) and palsies of cranial nerves (53%) were observed. Endoscopy findings showed necrosis (70%), discharge (61%), and crusting (54%). Imaging enhancement revealed mucosal thickening (69%), opacification of sinus (69%), bony destruction of sinus (35%), and orbital involvement (25%). Debridement surgery was necessary in nearly all patients (96%), dominated by ethmoid sinus (90%), maxillary sinus (87%), middle turbinate (80%), and sphenoid sinus (79%). Based on our follow-up, 25 patients died (42%). Those who survived will suffer from no light perception (35%), cranial nerve palsy (12%), and cerebral vascular accident (1.6%). Conclusion(s): Mucormycosis is an aggressive fungal infection. Diabetes mellitus, COVID-19 complication, inappropriate use of corticosteroids, and delayed vaccination had significantly increased its incidence. As there is an urgent need to address this public health concern, we present our data set from Iran.

5.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P281-P282, 2022.
Article in English | EMBASE | ID: covidwho-2064420

ABSTRACT

Introduction: India is one of the countries most affected by COVID-19. COVID-19-associated mucormycosis (CAM) has added to the woes of the already devastating effects of the virus. About 97.6% of cases in India presented with rhino-orbito-cerebral disease. Fibrous dysplasia (FD) is characterized by abnormal mixtures of fibrous and osseous elements leading to bony deformities and pathological fractures. Monostotic and polyostotic varieties have been described, with the latter being more common in children. The monostotic type of FD accounts for about 70% to 80% of FD, affecting the second and third decade. Method(s): We present a case of 44-year-old man with fibrous dysplasia of left maxilla with CAM, an angioinvasive fungal disease associated with high morbidity and mortality. As India and the entire world is struck by the COVID-19 pandemic, the use of corticosteroids has proven somewhat helpful in managing severe COVID infection. Evidence shows it has also led to CAM. Our patient was treated with radical surgical treatment of lesion with gross removal of all necrotic tissues from the sinuses along with antifungal treatment with amphotericin B. FD is a benign disorder characterized by replacement of normal bone with cellular fibrous connective tissue. Result(s): Our case presented with CAM of maxilla with palatal involvement requiring urgent surgical intervention and antifungal therapy. It incidentally happened to be a case of FD. Maxillectomy took care of the patient's FD as well. Conclusion(s): FD is a disorder characterized by dystrophy and bony metaplasia, and treatment depends on the zone of involvement. Early diagnosis and surgical intervention, with good antifungal therapy with strict glycemic control, are critical features to prevent its onslaught. Sometimes treatment of one condition can cure the others as well.

6.
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).

7.
Journal of the American Academy of Dermatology ; 87(3 Supplement):AB220, 2022.
Article in English | EMBASE | ID: covidwho-2061395

ABSTRACT

Introduction: White piedra is a rare superficial mycosis caused by the genus Trichosporon. Its prevalence is higher among tropical climates and predominantly affects children and women. Less than 17 cases have been described in Mexico, none of them in the Northeast region. We present the first case reported in this zone. Case presentation: A 27-year-old otherwise healthy woman presented to our clinic with a 1-month history of asymptomatic pseudonits on her scalp hair. Physical evaluation revealed numerous small white concretions over the majority of the hair shafts. At trichoscopic inspection, multiple white-yellowish ovoid nodules were observed. Direct microscopic examination with 20% potassium hydroxide (KOH) and blue cotton showed nodules composed of arthroconidia and hyphae over the hair shaft. Additionally, fungal culture was positive for Trichosporon inkin, confirming the diagnosis of white piedra. Treatment was initiated with ketoconazole shampoo and systemic itraconazole with favorable response. Discussion(s): Since the first case description by Beigel in Germany, most white piedra cases have been reported in tropical and humid climates. This mycosis typically affects females and subjects under 15 years of age. Some risk factors include poor hygiene, excess humidity, diabetes, and long, curly hair. In our case, the patient had curly hair and she constantly tied her hair up wet as she worked as a full-time nurse in a COVID-19 reference center. In our country, 50% of previous reported cases are from nontropical regions. Although infrequent in cosmopolitan areas in Northeast Mexico, white piedra should be considered in the differential diagnosis of pseudonits. Copyright © 2022

8.
Chest ; 162(4):A2046, 2022.
Article in English | EMBASE | ID: covidwho-2060892

ABSTRACT

SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Broncholiths are calcifications in the tracheobronchial tree that are most commonly associated with indolent infections. Disease manifestations range from asymptomatic stones in the airway to major complications such as massive hemoptysis or post-obstructive pneumonias. Depending on severity of the disease, patient management can range from conservative strategies to surgical interventions. We report successful reduction of a large obstructive broncholith in the right middle lobe via Holmium-yttrium aluminum garnet (Ho:YAG) laser lithotripsy. CASE PRESENTATION: Patient is a 55 year old male who presented with on going purulent cough, fever and pleuritic chest pain for 3 months. He had associated weight loss (>10 lbs in 3 months), malaise, increased fatigue, and scant hemoptysis. Initial chest x-ray was evident of right middle lobe consolidation. Respiratory infection panel, COVID PCR, AFB cultures and fungal cultures were negative. Subsequent CT of his chest showed right middle lobe opacities with areas of obstruction with a broncholith. Subsequently, patient underwent rigid bronchoscopy to allow for left sided airway protection via direct tamponade if patient develops massive hemoptysis. A bronchoscopic inspection was performed through the rigid scope that confirmed the broncholith. Obliteration of broncholith was then performed via Ho:YAG. After multiple laser treatments, we noted improvement in the size of the broncholith. Patient admitted to significant improvement in chest pain, hemoptysis and cough since the procedure. DISCUSSION: Broncholithiasis refers to calcified material eroding the tracheobronchial tree and causing inflammation and obstruction. Etiology of broncholiths include calcified peribronchiolar lymph nodes that erode into the airway lumen. Lymph node calcifications in the thorax are associated with lymphadenitis from fungal or mycobacterial infections. Management depends on the size of broncholiths. For larger stones, flexible bronchoscopy is often used to confirm diagnosis. When forceps extraction is not feasible, stone fragmentation with Ho:YAG is generally utilized, but they carry the risk of massive hemoptysis or bronchial injury. Surgical interventions, such as lobectomy or pneumonectomy, are reserved for patients with recurrent pneumonias, bronchiectasis, bronchial stenosis or broncho-esophageal or aorto-tracheal fistulas. In our case, we demonstrate successful reduction of a non-mobile broncholith by protecting the airway using rigid bronchoscopy by interventional pulmonology and subsequently avoiding surgical intervention in a patient with repeated post-obstructive pneumonia. CONCLUSIONS: Management of broncholiths should be individualized for symptomatic patients. A comprehensive assessment with appropriate imaging and involvement of interventional pulmonology can result in successful reduction of the stone and minimizing complications. Reference #1: Dakkak, M., Siddiqi, F., & Cury, J. D. (2015). Broncholithiasis presenting as bronchiectasis and recurrent pneumonias. Case Reports, 2015, bcr2014209035. Reference #2: Krishnan, S., Kniese, C. M., Mankins, M., Heitkamp, D. E., Sheski, F. D., & Kesler, K. A. (2018).Management of broncholithiasis. Journal of thoracic disease, 10(Suppl 28), S3419. Reference #3: Olson, E. J., Utz, J. P., & Prakash, U. B. (1999). Therapeutic bronchoscopy in broncholithiasis. American journal of respiratory and critical care medicine, 160(3), 766-770 DISCLOSURES: No relevant relationships by Jalal Damani No relevant relationships by Joseph Gatuz No relevant relationships by Fereshteh (Angel) Yazdi

9.
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

10.
Chest ; 162(4):A1635-A1636, 2022.
Article in English | EMBASE | ID: covidwho-2060850

ABSTRACT

SESSION TITLE: Challenges in Lung Tumors SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Patients can have a variety of post Coronovirus induced disease (COVID) associated interstitial lung diseases (ILD) ranging from cystic lung disease to fibrinous organizing pneumonia. However, very little is known about malignancies that have been overshadowed by post COVID associated pulmonary changes. We present one such case of insidious invasive mucinous adenocarcinoma of the lung that was masked by post COVID related changes. CASE PRESENTATION: A 70 year old female with COPD, systolic heart failure and significant tobacco use disorder presented with progressively worsening hypoxemic respiratory failure. She has had 4 hospitalizations in past year all for acute on chronic hypoxemic respiratory failure following COVID. She has been on Supplemental Oxygen 3L/min since her infection with SARS-COV2. Patient was found to have worsening bibasilar ground glass opacities (GGO) on CT of chest over the past 1 year since having COVID. She was treated with several rounds of steroids without any relief. Patient had a PET scan that showed a very avid left upper lobe consolidation. Given these worsening abnormalities and symptoms, she underwent bronchoscopy with transbronchial biopsy guided by the positive PET scan and fluoroscopy. However, during bronchoscopy she had copious secretions which were therapeutically cleared helping relieve some of patient's hypoxemia. All her cultures and Fungitell assay on bronchoalveolar lavage were negative. However, post biopsy pathology came back positive for Invasive Mucinous Adenocarcinoma. Patient was treated with chemo and radiation therapy with good response against her malignancy and significant relief in her hypoxemia. DISCUSSION: COVID associated pneumonia is well known to cause chronic hypoxemic respiratory failure. Post COVID related pulmonary changes range from organizing pneumonia to fungal pneumonia. However, patients should start to recover with time as inflammatory changes resolve on CT scan with adequate steroids or anti-fungals. If patients continue to deteriorate then a prompt work-up that rules out other infections and even malignancies is warranted as seen in our patient. This case brings forth an important consideration for aggressively pursuing an adequate work-up in the face of worsening GGO on the CT and patient's continual deterioration due to her hypoxemic respiratory failure. Our patient was able to be adequately diagnosed with malignancy and was then started on chemotherapy that allowed for adequate control of her hypoxemic respiratory failure and helped improve her quality of life. CONCLUSIONS: Post COVID related pulmonary changes can be from a variety of ILD and infections. However, clinician should be vigilant in considering malignancy as a possible etiology of post COVID related changes and initiate an adequate work-up to help evaluate for cancer that can be masked amongst post COVID related ILD. Reference #1: Beck KS, Sung YE, Lee KY, Han DH. Invasive mucinous adenocarcinoma of the lung: Serial CT findings, clinical features, and treatment and survival outcomes. Thorac Cancer. 2020 Dec;11(12):3463-3472. doi: 10.1111/1759-7714.13674. Epub 2020 Oct 5. Reference #2: Matsui T, Sakakura N, Koyama S, Nakanishi K, Sasaki E, Kato S, Hosoda W, Murakami Y, Kuroda H, Yatabe Y. Comparison of Surgical Outcomes Between Invasive Mucinous and Non-Mucinous Lung Adenocarcinoma. Ann Thorac Surg. 2020 Nov 24:S0003-4975(20)32001-4. doi: 10.1016/j.athoracsur.2020.09.042. Epub ahead of print. Reference #3: Lee MA, Kang J, Lee HY, Kim W, Shon I, Hwang NY, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Spread through air spaces (STAS) in invasive mucinous adenocarcinoma of the lung: Incidence, prognostic impact, and prediction based on clinicoradiologic factors. Thorac Cancer. 2020 Nov;11(11):3145-3154. doi: 10.1111/1759-7714.13632. Epub 2020 Sep 25. DISCLOSURES: No relevant relationships by Danya Ahmed No relevant relationships by David Chambers No rele ant relationships by Jalal Damani No relevant relationships by Deon Ford No relevant relationships by Rachaita Lakra

11.
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

12.
Chest ; 162(4):A911-A912, 2022.
Article in English | EMBASE | ID: covidwho-2060726

ABSTRACT

SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Superimposed bacterial co-infection is common among patients with Coronavirus disease-19 (COVID-19) pneumonia. Incidence of any superimposed infection ranges from 0% to 40%. Up to 50% of COVID-19 patients who died, had concomitant bacterial or fungal infection. Steroids are recommended for the treatment of acute hypoxemic respiratory failure (AHRF) due to COVID-19 and are thought to mitigate inflammatory organ injury. This retrospective study explores a subset of COVID-19 patients receiving Epoprostenol (iEPO) for AHRF and compared two different steroid treatment strategies and the impact on patient outcomes. METHODS: This is a retrospective study of 101 COVID-19 patients with AHRF receiving iEPO and systemic steroids. Patients in the high dose steroid group (n=59) received a minimum of dexamethasone 20mg daily or solumedrol 100mg daily while the standard dose steroid group (n=52) were those who received any lower dose. Patients that were DNR/I were excluded from the study. The primary outcome of the study was the rate of bacterial co-infection defined by positive cultures. Secondary outcome was mortality. RESULTS: Results showed that patients treated with high dose steroids were older (66.77±11.17 vs 60.33±14.49, p0.006) and received a longer treatment course (18 days (12-25) vs 12.5 days (10-17), p 0.004). Univariate and Multivariate analysis showed that higher dose steroids were not associated with increased risk of superimposed bacterial infection (OR 0.96, CI (0.34-2.66), p0.93). The duration of steroids, regardless of the dose, was associated with increased risk of superimposed bacterial infection (OR 1.06, CI (1.01-1.13), p0.033). When adjusted for comorbidities and inflammatory state, there was no significant difference in mortality between patients treated with high dose compared to standard dose steroids (OR 3.60, CI (0.65-19.93), p0.14). A longer duration of steroids was associated with a trend towards improved mortality (OR 0.93, CI (0.87-1.00), p0.072). CONCLUSIONS: Our study suggests that the duration of steroids, rather than dosage, had an effect on patient outcomes. There was no difference in bacterial co-infection rates between the two groups, but infection rates were increased among those who received a longer course of steroid treatment. There was a trend towards lower mortality with increased steroid duration, however, this did not reach statistical significance. Given this trend towards lower mortality, future prospective studies should investigate steroid duration to determine if a longer course of treatment leads to better outcomes in patients with COVID-19 pneumonia and refractory AHRF. CLINICAL IMPLICATIONS: Based on our study, patients should not receive a higher dose or longer duration of steroid treatment given the increased risk of bacterial infection with no definitive improvement in mortality. DISCLOSURES: No relevant relationships by Natasha Garg No relevant relationships by Abhinav Hoskote No relevant relationships by Raymonde Jean No relevant relationships by Arpanjeet Kaur No relevant relationships by Sara Luby No relevant relationships by Omar Mahmoud No relevant relationships by Maria Athena Riego No relevant relationships by Edith Robin No relevant relationships by James Salonia No relevant relationships by DISHANT SHAH No relevant relationships by Venus Sharma No relevant relationships by Elizabeth Zipf

13.
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

14.
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

15.
Chest ; 162(4):A549, 2022.
Article in English | EMBASE | ID: covidwho-2060626

ABSTRACT

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: To evaluate the incidence of fungal co-infections clinical characteristics, and outcomes in patients with COVID-19. METHODS: We conducted a retrospective chart review of electronic medical records of 2,639 adult patients admitted for COVID -19 to our health system from April 1, 2020 to December 31, 2021. Demographic data, comorbidities, length of hospital stay, laboratory results including fungal diagnostics, COVID therapeutics and antifungals, need for ICU admission, mechanical ventilation and in-hospital mortality were collected. RESULTS: A total of 45 of 2,639 (1.7%) COVID-19+ patients had a positive fungal test or culture of fungal pathogen and subsequently received antifungal treatment. Of these 25 (55.6%) cases of Aspergillus species were the most prominent, followed by Candida species at 12 (26.7%). Of note, there was one case each of Cryptococcus and Histoplasma (2.2%). COVID-19+ patients with fungal co-infection who survived (18;40%) were significantly younger compared to COVID-19+ patients with fungal co-infection who died (27;60%, p=0.014). Majority of COVID-19+ patients with fungal co-infection were white with average length of hospitalization of 24 days. Those patients who survived had a significantly longer length of hospitalization compared to COVID-19+ patients who died (survived 31 ± 21.5 compared to 19.6 ± 10.4 days, p<0.05). Majority of COVID-19+ patients received steroids, and remdesivir therapy for COVID-19. Antifungal treatment consisted of either voriconazole or micafungin as predominate fungal pathogens were either Aspergillus or Candida spp. CONCLUSIONS: Pulmonary aspergillosis followed by invasive candidiasis were the most common fungal co-infections in COVID-19 patients treated at our institution. In-hospital mortality from all fungal co-infections was 60%. Patients that survived were younger and hospitalized longer compared to those who expired. Need for mechanical ventilation, ICU admission and COVID therapeutics were not significantly different between the survived and expired group of COVID-19 patients with fungal co-infections. CLINICAL IMPLICATIONS: The increased risk and incidence of COVID-19 and fungal co-infection has been noted in a handful of studies with invasive aspergillosis being the most commonly reported fungal co-infection. There have been very few reports of other fungal co-infections including invasive candidiasis, mucormycosis, histoplasmosis, and cryptococcosis. Minimal incidence data has been reported on co-infection with other opportunistic fungal pathogens such as Histoplasma spp., Pneumocystis jirovecci, or Cryptococcus neoformans. This study supports previous findings of increase risk of Aspergillosis, but also show incidence of Histoplasmosis and Crytpococcal fungal infections. These fungal infections may be under reported in COVID-19 and may warrant further research. DISCLOSURES: No relevant relationships by Christopher Destache No relevant relationships by Rutendo Jokomo-Nyakabau No relevant relationships by Dorothy Kenny No relevant relationships by Paul Millner No relevant relationships by Anny Nguyen No relevant relationships by Mohammad Selim No relevant relationships by Richard Swaney No relevant relationships by Manasa Velagapudi

16.
Chest ; 162(4):A548, 2022.
Article in English | EMBASE | ID: covidwho-2060625

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: Pulmonary aspergillosis is a recognized complication of COVID-19. Options for diagnostic evaluation in patients with suspected pulmonary aspergillosis include serum galactomannan, beta-D-glucan, Aspergillus PCR, fungal cultures and tissue biopsy. Diagnosis is challenging due to the risks and logistical barriers associated with procedural/surgical tissue biopsy and the variable reliability of serum biomarkers. We present a case of a 76-year-old male who developed invasive pulmonary aspergillosis after a COVID-19 respiratory infection. CASE PRESENTATION: 76-year-old male with a past medical history that includes emphysematous COPD, history of chronic lymphocytic leukemia in remission, on ibrutinib, who contracted SARS-CoV-2 resulting in hypoxemic respiratory failure and requiring hospital admission and was treated with dexamethasone and remdesivir. He was discharged home and due to his worsening respiratory condition, he was readmitted to the hospital next month. Ct chest performed revealed pulmonary embolism and diffuse multifocal opacification with interspersed scattered dense opacities and nodules with cavitary lesions in the right upper lobe. A bronchoscopy was performed and the Aspergillus antibody test, beta D glucan and galactomannan antigens resulted as negative. Due to this, voriconzaole was discontinued. Subsequently CT-guided lung biopsy demonstrated Aspergillus. Eventually, fungal cultures from BAL began growing fungus. DISCUSSION: Our patient initially presented with a Covid infection in January 2022 he was initially treated with remdesivir, 14 days of baricitinib and 10 days of Decadron followed by a steroid taper (due to his underlying COPD). He did not receive tocilizumab. He was found to have progression of the cavitary lesions during a third admission. We suspect that the main contributing factors for the development of invasive pulmonary aspergillosis are related to interleukin production, distorted architecture from COVID-19 infection and multiple courses of steroids. This case report demonstrates the importance of having a high clinical suspicion for invasive pulmonary aspergillosis in all patients with COVID-19 infection. It also demonstrates that serum biomarkers are not reliable indicators of infection and cannot be used to definitively rule out infection or to exclude treatment with antifungal therapy. It should be noted that positive serum biomarkers in patients with true invasive aspergillosis have a higher mortality rate as compared to those without positive serum biomarkers. This case also underscores the importance of obtaining tissue diagnosis in patients where there is a high suspicion for fungal infection when all other studies are equivocal. CONCLUSIONS: We believe that this case underscores the importance of maintaining a high clinical suspicion for opportunistic and fungal infections in patients with COVID-19, regardless of the serum biomarkers. Reference #1: Arastehfar A, Carvalho A, van de Veerdonk FL, et al. Covid-19 associated Pulmonary Aspergillosis (capa)—from immunology to treatment. Journal of Fungi. 2020;6(2):91. doi:10.3390/jof6020091 Reference #2: Machado M, Valerio M, Álvarez-Uría A, et al. Invasive Pulmonary Aspergillosis in the COVID-19 ERA: An expected new entity. Mycoses. 2020;64(2):132-143. doi:10.1111/myc.13213 Reference #3: Maschmeyer G, Haas A, Cornely OA. Invasive aspergillosis. Drugs. 2007;67(11):1567-1601. doi:10.2165/00003495-200767110-00004 DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Amanda Lindo No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore

17.
Chest ; 162(4):A495, 2022.
Article in English | EMBASE | ID: covidwho-2060611

ABSTRACT

SESSION TITLE: Severe and Unusual Blastomycosis Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: The diagnosis of blastomycosis is often delayed due to its non-specific symptoms and imaging findings. Clinicians must have a high clinical index of suspicion to diagnose blastomycosis in a timely manner, especially in the setting of the current COVID-19 pandemic. CASE PRESENTATION: A healthy 44-year-old male presented to an urgent care center with complaints of cough, fevers, and malaise. CT scan of the chest revealed a left upper lobe mass concerning for rounded bacterial pneumonia versus malignancy. He was found to be COVID-19 positive. The patient was sent home with steroids and antibiotics. Three months later, a repeat CT scan of the chest was obtained which revealed progression of the consolidation and prompted further evaluation at the hospital. On presentation, he reported a persistent cough, weight loss, and the development of multiple painful nodules on his extremities and trunk within the past week. A skin lesion was biopsied. A bronchoscopy was also performed for biopsy and brushing. Biopsy of the skin lesion as well as specimens collected from the bronchoscopy resulted positive for Blastomyces. MRI of the brain demonstrated multiple enhancing lesions concerning for septic emboli. He was started on amphotericin B for treatment of disseminated blastomycosis with central nervous system (CNS) involvement. Repeat imaging of the brain and chest about 3 weeks after initiation of therapy showed interval decrease in the size of the lesions. He was then transitioned to oral itraconazole and discharged home. DISCUSSION: Blastomycosis is an endemic fungal infection that can affect immunocompetent and immunocompromised hosts. It tends to infect immunocompetent hosts more so than other invasive fungal infections. Symptoms can range from asymptomatic to rapidly progressive acute respiratory distress syndrome (ARDS). Disseminated blastomycosis has been reported in 20-50% of patients (1). In the above case, an immunocompetent patient developed pulmonary and dermatologic manifestations concerning for disseminated blastomycosis. Though he had no recent travel, occupational exposures, or contact with any construction work, the patient was living in an endemic area for Blastomyces. It is difficult to definitively ascertain if the patient already had pulmonary blastomycosis when he was diagnosed with COVID-19, but his extrapulmonary manifestations clearly developed after the diagnosis. Earlier detection and treatment of the pulmonary blastomycosis may have prevented the dissemination of the disease. CONCLUSIONS: This case serves as a reminder to consider other infectious etiologies, like endemic fungal infections, in the midst of the COVID-19 pandemic to prevent delays in treatment and progression of these diseases. Reference #1: McBride JA, Gauthier GM, Klein BS. Clinical Manifestations and Treatment of Blastomycosis. Clin Chest Med. 2017 Sep;38(3):435-449. doi: 10.1016/j.ccm.2017.04.006. Epub 2017 Jun 12. PMID: 28797487;PMCID: PMC5657236. Reference #2: Cafardi J, Haas D, Lamarre T, Feinberg J. Opportunistic Fungal Infection Associated With COVID-19. Open Forum Infect Dis. 2021 Jan 18;8(7):ofab016. doi: 10.1093/ofid/ofab016. PMID: 34621913;PMCID: PMC7928619. DISCLOSURES: No relevant relationships by Shannon Burke No relevant relationships by Abigail Go No relevant relationships by Jen Minoff No relevant relationships by David Stoeckel

18.
Chest ; 162(4):A462, 2022.
Article in English | EMBASE | ID: covidwho-2060600

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: Mucormycosis is an angio-invasive fungal infection with substantial morbidity and mortality. While diabetes and immune suppression remain well-known risk factors for mucormycosis, COVID-19 is now emerging as its independent predictor. CASE PRESENTATION: A 43-year-old male, with a history of hyperlipidemia and alcoholism, presented to the hospital with complaints of progressive dyspnea on exertion, productive cough, intermittent fever, anorexia, and chest pain over the course of 2 weeks. About 5 weeks prior to the current presentation, he was tested positive for COVID-19 by a polymerase chain reaction (PCR) based test and remained in quarantine at home. He was not vaccinated against COVID-19. He had no known immunosuppressive disease. On initial examination, he was ill-appearing and had a temperature of 101 F, blood pressure 138/83 mmHg, respiratory rate 22/minute, pulse 102/minute, and saturation of 91% on 2 L nasal cannula oxygen. A computerized tomography (CT) scan of the chest revealed small bilateral pneumothorax (2 cm and 5mm) along with extensive ground-glass opacifications in all lobes. In the next 24 hours, the right-sided pneumothorax progressed to tension pneumothorax requiring pigtail pleural drainage catheter placement. The drained pleural fluid had more than 100,000/uL total nucleated cells (91% neutrophils, 2% lymphocytes, and 1% eosinophils) and ultimately cultures grew Rhizopus spp. He was started on intravenous liposomal amphotericin-B infusion (5 mg/kg daily). On hospital discharge, he was switched to oral posaconazole (started with loading 300 mg delayed-release tablet twice a day, followed by 300 mg dosing of delayed-release posaconazole tablets daily) to complete the long term treatment course. DISCUSSION: Most of the reported cases of mucormycosis in COVID-19 were in patients with either diabetes or receiving steroids. This is a rare presentation of COVID-19–associated pulmonary mucormycosis (CAPM) as spontaneous pneumothorax, in the absence of known immunosuppression history. COVID-19 results in a considerable increase in cytokines, particularly interleukin-6 (IL-6), which increase free iron by increasing ferritin levels due to increased synthesis and decreased iron transport. Also, concomitant acidosis increases free iron by reducing the ability of transferrin to chelate iron and this available iron becomes a considerable resource for mucormycosis. [1] Also, Mucorales adheres to and invades endothelial cells by specific recognition of the host receptor glucose-regulator protein 78 (GRP-78). Acidosis associated with severe COVID-19 triggers GRP-78 and fungal ligand spore coating homolog (CotH) protein expression on endothelial cells, both contributing to angioinvasion, hematogenous dissemination, and tissue necrosis. [2] CONCLUSIONS: Mucormycosis can present as spontaneous pneumothorax after recent COVID-19 and clinicians should be aware of rare clinical presentation. Reference #1: Singh AK, Singh R, Joshi SR, et al. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021;15:102146. doi:10.1016/j.dsx.2021.05.019 Reference #2: Baldin C, Ibrahim AS. Molecular mechanisms of mucormycosis—The bitter and the sweet. PLOS Pathog 2017;13:e1006408. doi:10.1371/journal.ppat.1006408 DISCLOSURES: No relevant relationships by Faran Ahmad No relevant relationships by AYESHA BATOOL No relevant relationships by Zachary DePew No relevant relationships by Neil Mendoza

19.
Chest ; 162(4):A448, 2022.
Article in English | EMBASE | ID: covidwho-2060598

ABSTRACT

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Since the start of Covid-19 pandemic, several respiratory microorganisms have been identified that cause coinfection with Sars-Cov-2. Bacteria like Staphylococcus aureus and viruses like influenza are some of the identified pathogens. Rarely, fungal infections from Aspergillus are also being reported. CASE PRESENTATION: 59-year-old male with past medical history of hypertension and hyperlipidemia was admitted for shortness of breath and was found to be positive for Covid-19. He received Remdesivir, dexamethasone & tocilizumab. He required non-invasive ventilation via continuous positive airway pressure but continued to remain hypoxemic with elevated procalcitonin, he was treated with cefepime for bacterial pneumonia. Patient required emergent intubation and eventually underwent tracheostomy. He developed methicillin-resistant Staphylococcus aureus pneumonia for which he received vancomycin. He was eventually discharged to long term acute care facility. Patient was readmitted after 2 months due to worsening respiratory status. Computed Tomography Angiography of chest was negative for pulmonary embolism but showed pleural effusion. He underwent thoracentesis which showed exudative effusion with negative cultures. Echocardiogram showed right heart failure. Patient's symptoms were believed to be due to Covid-19 fibrosis. He required home oxygen and also received pulmonary rehabilitation. One year after the initial Covid-19 infection, he developed pulmonary hypertension and was referred for lung transplant consultation. However, he developed severe hemoptysis requiring intubation and vasopressors. Galactomannan was positive, Karius digital culture revealed Aspergillus Niger for which he received voriconazole. He was not deemed a suitable candidate for lobectomy. Patient developed arrhythmia and had prolonged QT interval so voriconazole was switched to Isavuconazole. He continued to have hemoptysis and his condition did not improve so family requested to transition care and patient passed away. DISCUSSION: Several studies have proven co-infection of Aspergillus with Covid-19. This case highlights Aspergillus infection approximately 1 year after initial Covid-19 infection. Sars-Cov-2 causes damage to airway lining which can result in Aspergillus invading tissues. IL-6 is increased in severe Covid-19 infection. Tocilizumab is an anti-IL-6 receptor antibody that has been approved for treatment of Covid-19 pneumonia. However, IL-6 provides immunity against Aspergillus so use of tocilizumab decreases protection against Aspergillosis which is usually the reason for co-infection. However, in this case patient developed fungal infection later during Covid-19 fibrosis stage. CONCLUSIONS: Recognizing fungal etiology early on is important in Covid-19 patients as mortality is high and appropriate intervention can reduce morbidity and mortality. Some patient may eventually require lung resection. Reference #1: Kakamad FH, Mahmood SO, Rahim HM, Abdulla BA, Abdullah HO, Othman S, Mohammed SH, Kakamad SH, Mustafa SM, Salih AM. Post covid-19 invasive pulmonary Aspergillosis: a case report. International journal of surgery case reports. 2021 May 1;82:105865. Reference #2: Nasrullah A, Javed A, Malik K. Coronavirus Disease-Associated Pulmonary Aspergillosis: A Devastating Complication of COVID-19. Cureus. 2021 Jan 30;13(1). Reference #3: Dimopoulos G, Almyroudi MP, Myrianthefs P, Rello J. COVID-19-associated pulmonary aspergillosis (CAPA). Journal of Intensive Medicine. 2021 Oct 25;1(02):71-80. DISCLOSURES: No relevant relationships by Maria Haider Baig

20.
Chest ; 162(4):A432-A433, 2022.
Article in English | EMBASE | ID: covidwho-2060596

ABSTRACT

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: Since its emergence in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has spread across the world, claiming millions of lives. With the publication of RECOVERY trial and REMAP-CAP trial, tocilizumab is recommended as additional therapy in select COVID populations by various professional societies. Although not observed initially in several randomized trials, concerns regarding serious secondary infections have been raised. Hereby, we seek to describe the epidemiology of infectious complications after tocilizumab in COVID patients admitted to a tertiary community hospital and to determine related risk factors for infections. METHODS: A retrospective cohort study was conducted among COVID patients requiring noninvasive or invasive ventilation who received tocilizumab at our hospital between June 2020 to December 2021. We define infectious complications as positive culture grown on a specimen that was also treated with antibiotics by the primary team. Baseline demographics and laboratory values are obtained through electronic medical records. Continuous outcomes are analyzed with parametric and non-parametric testing. Categorical variables are analyzed using the Chi-Square test. Risk factors are identified through Probit regression analysis and stepwise analysis. Statistics are performed using SPSS and STATA. RESULTS: 52 patients are identified with a median age of 63 and 46.2% female sex. Median hospital admission time since COVID diagnosis is 2 days and median tocilizumab administered time is 6.5 days. Common comorbidities include hypertension (63.5%), hyperlipidemia (50%) and diabetes (44.2%). Infectious complications are documented in 30 patients (57.7%), with 29 episodes of pneumonia, 7 episodes of urinary tract infection, and 4 episodes of bacteremia. Common organisms include MSSA (21%), Pseudomonas aeruginosa (19%), Klebsiella species (13%) and MRSA (5%). There are 9 cases of multidrug-resistant bacterial infection and 3 episodes of invasive fungal infection (1 Candidemia and 2 invasive aspergilloses). 22 patients (43.3%) died in the hospital before discharge with a median alive time after tocilizumab of 16.5 days. Hyperglycemia on admission (defined as a random glucose >200 mg/dl), hypertension and antibiotic use before tocilizumab are independent risk factors associated with infectious complications during regression analysis. Age >65 is the single most significant factor associated with death in the hospital. CONCLUSIONS: In real-world experience, infectious complications are not uncommon in COVID patients who receive tocilizumab. Our analyses show that potential risk factors for developing infections include a history of hypertension, hyperglycemia on admission and antibiotic use before tocilizumab. CLINICAL IMPLICATIONS: More rigorous criteria in patient selection and patient monitoring should be explored in future trials involving tocilizumab in COVID patients. DISCLOSURES: No relevant relationships by Zauraiz Anjum No relevant relationships by Ming-Yan Chow No relevant relationships by Ahmed Elkhapery No relevant relationships by Hafsa Faisal No relevant relationships by Lakshmi G Nair No relevant relationships by Charoo Iyer No relevant relationships by Hongli Liu No relevant relationships by Chengu Niu No relevant relationships by Kaiwen Zhu

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