E. COLI PNEUMONIA WITH PNEUMATOCELE, EMPYEMA NECESSITANS, AND BRONCHOPLEURAL FISTULA IN A PATIENT WITH SEVERE COVID-19

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tocilizumab, an interleukin-6 inhibitor used in rheumatologic disease and cytokine release syndrome, is one of many investigational drugs used for coronavirus disease-19 pneumonia (COVID). While the safety profile has been well studied, there is little known about its effect on opportunistic infections (OI) risk in patients with COVID. We present a 43-year-old man with COVID who received tocilizumab and subsequently developed cavitating lung lesions suspicious for invasive aspergillosis. CASE PRESENTATION: A 43-year-old man with diabetes mellitus was admitted for hypoxemic respiratory failure (HRF). Nasopharyngeal swab polymerase chain reaction was positive for COVID. He was placed on high-flow nasal cannula (HFNC), and on day 10 he was intubated for worsening HRF. He was treated with ceftriaxone, azithromycin, methylprednisolone, convalescent plasma, and tocilizumab. Antibiotics later included ertapenem due to E. coli with extended-spectrum beta lactamase (ESBL) found in sputum culture. He was extubated on day 15 and oxygen requirements were weaned to HFNC. However, bronchial aspirate cultures from day 14 grew mold and subsequent serologies were positive for Aspergillus. Chest computerized tomography (CT) was notable for the development of multiple new cavitary lesions concerning for invasive pulmonary aspergillosis. The patient was initially treated with voriconazole and later with amphotericin B due to liver enzyme elevation. The patient’s oxygen requirements initially decreased, however on day 30 the patient suffered an aspiration event and was reintubated. Subsequent CT was concerning for worsening of cavitary lung disease. Bronchoalveolar lavage was collected, which tested positive for Aspergillus galactomannan. On hospital day 31, the patient suffered a left-sided tension pneumothorax requiring tube thoracostomy. At the time of submission the patient remains critically ill. DISCUSSION: Influenza-associated pulmonary aspergillosis (IAPA) is a known complication of severe influenza.1,2 Similarly, COVID-associated pulmonary aspergillosis (CAPA) may become an emerging problem given the overwhelming inflammation and use of experimental immunosuppressive therapies in COVID.1,2 While tocilizumab has not been shown to increase risk of Aspergillus infection in rheumatologic disease, it has not been studied in COVID and the risk of OI in an already-susceptible group may outweigh the benefits of using this drug in patients with COVID.3 If CAPA is similar to IAPA, BAL galactomannan is the gold standard for diagnosis.2 CONCLUSIONS: As the medical community searches for COVID treatments, these patients’ potentially inherent vulnerability to OI may be under-appreciated. When using immunosuppressive agents to curtail the inflammatory cascade, the risk of OI must be considered and agents like tocilizumab must be further studied in this context. Reference #1: Koehler P, Cornely OA, Böttiger BW, et al. COVID-19 associated pulmonary aspergillosis. Mycoses. 2020;63(6):528-534. Reference #2: van Arkel ALE, Rijpstra TA, Belderbos HNA, van Wijngaarden P, Verweij PE, Bentvelsen RG. COVID-19 associated pulmonary aspergillosis. Am J Respir Crit Care Med. 2020;online May 2020. Reference #3: Kourbeti IS, Ziakas PD, Mylonakis E. Biologic therapies in rheumatoid arthritis and the risk of opportunistic infections: a meta-analysis. Clin Infect Dis. 2014;58(12):1649-57. DISCLOSURES: No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response No relevant relationships by Richard Watson, source=Web Response