COVID-19-INDUCED IMMUNOSUPPRESSION LEADING TO SECONDARY INFECTION AS DISSEMINATED COCCIDIOIDOMYCOSIS

ABSTRACT

SESSION TITLE Post-COVID-19 Infection Complications SESSION TYPE Case Report Posters PRESENTED ON 10/17/2022 1215 pm - 0115 pm INTRODUCTION: Coccidioidomycosis caused by the fungi C. immitis and C. Posadasii is well known to be endemic to the Southwest United States. Less than 1% of these infections will manifest as extrapulmonary symptoms and multiple sites causing dissemination fungemia [1]. Risk factors for disseminated infection include exogenous immunosuppression, immunodeficiency, pregnancy, and ethnic backgrounds of African and Filipino descent [2]. CASE PRESENTATION A 39-year-old previously immunocompetent Congolese male with recent onset of recurrent skin abscess, and positive testing for COVID-19 three week prior (not treated with steroids). He presents with shortness of breath, back pain, fevers after recently migrating from the Southwest region to the Midwest. Upon admission imaging with Computed Tomography (CT) revealed extensive pulmonary infiltrates (Fig 1), intra-abdominal abscesses, and magnetic resonance imaging revealing (MRI) osteomyelitis of the thoracic (Fig 2) and lumbar spine (Fig 3). His work of breathing continued to worsen, requiring prompt intubation, and he was initiated on a broad-spectrum antimicrobial regimen, including fluconazole, voriconazole, cefepime and vancomycin. Immunoglobulins, HIV and oxidative burst testing was unremarkable. Cultures from image-guided aspiration of the psoas abscess, incision, and drainages of skin abscess and bronchoalveolar lavage fluid were all positive for coccidioidomycosis, transitioned to amphotericin B. Course complicated with the development of multidrug-resistance pseudomonas aerogenes VAP treated with inhaled tobramycin and meropenem. He developed progressive acute respiratory distress syndrome with refractory hypoxemia. After 3 weeks of antimicrobial and anti-fungal treatment, a decision was made to transfer the patient to a lung transplant center, however, due to ongoing fungemia, he was deemed to be not a candidate for extracorporeal membrane exchange and lung transplantation. About a month into his hospitalization, the family decided to withdraw care. DISCUSSION: Reactivation of latent coccidiomycosis has been largely studied in the immunosuppressed population that includes HIV, hematological malignancies, and diabetes mellitus, however little is known about this fungal infection in the immunosuppressed state in the setting of COVID-19. Thus far only two case reports have been reported of co-infection if COVID-19 and pulmonary coccidioidomycosis [3]. The days of the COVID-19 pandemic might contribute to further delays in diagnosing this fungal infection due to similarities of pulmonary manifestation. CONCLUSIONS: This case demonstrates a COVID-19 infection leading to an immunosuppressed status resulting in disseminated infection from reactivation of latent coccidiomycosis. As a result, physicians must maintain a high level of suspicion for superimposed fungal infections in those with even relative immunosuppression from a recent COVID infection. Reference #1 Odio CD, Marciano BE, Galgiani JN, Holland SM. Risk Factors for Disseminated Coccidioidomycosis, United States. Emerg Infect Dis. 2017;23(2)308-311. doi10.3201/eid2302.160505 Reference #2 Hector RF, Laniado-Laborin R. Coccidioidomycosis–a fungal disease of the Americas. PLoS Med. 2005;2(1)e2. doi10.1371/journal.pmed.0020002 Reference #3 Shah AS, Heidari A, Civelli VF, et al. The Coincidence of 2 Epidemics, Coccidioidomycosis and SARS-CoV-2 A Case Report. Journal of Investigative Medicine High Impact Case Reports. January 2020. doi10.1177/2324709620930540 DISCLOSURES No relevant relationships by Stephen Doyle No relevant relationships by Connor McCalmon No relevant relationships by John Parent No relevant relationships by Jay Patel No relevant relationships by Angela Peraino No relevant relationships by Keval Ray