A case of burkholderia gladioli ventilator-associated pneumonia in a patient with COVID-19

ABSTRACT

INTRODUCTION: Burkholderia gladioli (B. gladioli) is primarily a plant pathogen but has been known to be pathogenic in patients with cystic fibrosis, chronic granulomatous disease or immunocompromised. METHODS: We hereby report a case of B. gladioli causing ventilator-associated pneumonia (VAP) in a patient with COVID-19. 68-year-old Hispanic man with a history of hypertension, type 2 diabetes mellitus, chronic kidney disease, and complete heart block with pacemaker presented to primary care office with fatigue, worsening shortness of breath, and decreased urine output for 2 days. He was found to be in acute respiratory distress with bilateral coarse breath sounds and saturating 60% on room air subsequently sent to ER for further evaluation. Transitioned to 100% high flow in the ER and was admitted to ICU. Pertinent work up showed pH of 7.2, bicarbonate (10 mmol/L), lactate (7.2 mmol/L), creatinine (5.5 mg/dl), d-dimer (2.0 mg/L), LDH (745 u/l), ferritin (5934 ng/mL). Chest x-ray showed bilateral infiltrates. Further increase in oxygen requirements required intubation. Intravenous ceftriaxone and azithromycin were started empirically for community-acquired pneumonia. Given his clinical presentation, PCR for SARS-Cov-2 was positive. He was treated with convalescent plasma and dexamethasone with decreasing ventilatory requirements and inflammatory markers. On day 13 of admission, the patient became febrile, WBC count of 24.4 k/ul, and increasing ventilatory requirements raising concern for VAP. Intravenous vancomycin and cefepime were started. Computed tomography pulmonary angiogram showed extensive pulmonary consolidation. Sputum culture grew B. gladioli. Based on susceptibilities levofloxacin was added to the antibiotic regime and cefepime was later switched to meropenem for double coverage in this critically ill patient. Despite aggressive management, he suffered multi-organ failure including acute respiratory distress syndrome (ARDS), acute renal injury requiring continuous renal replacement therapy, and shock unresponsive to vasopressors. The patient suffered cardiac arrest and died. RESULTS: COVID-19 pneumonia might have predisposed our patient to VAP with this rare organism. In spite of prompt recognition and aggressive treatment of infection, the outcome was fatal.