POSTPARTUM COVID-19 COMPLICATED BY BLASTOMYCOSIS INFECTION

Abstract

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Superadded infection in COVID- 19 ARDS has been imposing a significant challenge for early diagnosis and treatment. While SARS-CoV-2-associated pulmonary aspergillosis (CAPA) has been the predominant fungal disease seen in critically ill patients, we present an interesting case of pulmonary blastomycosis reactivation in COVID ARDS in a young post partum female, who recovered with extensive post infection lung damage CASE PRESENTATION: 24 years old gravida (G3P3) presented to ED with complaints of fever, cough and dyspnea for 1 week prior to presentation. Was initially discharged on CAP directed antibiotics. However, patient returned 10 days later with worsening dyspnea and found to have CTA chest imaging of extensive diffuse parenchymal consolidation. COVID PCR resulted positive and patient was admitted and treated with course of dexamethasone, remdesivir, and broad spectrum antibiotics. Unfortunately, developed rapidly progressive ARDS with clinical and radiographic worsening. Ultimately requiring critical care admission, intubation and emergent C-section at 31 weeks of gestation. Management strategies for severe ARDS were implemented including lung protective ventilation, proning, paralysing and inhaled nitric oxide. Eventually, patient was transferred to a tertiary care academic center for evaluation for VV ECMO. Worsening hypoxemic and hypercapnic ventilatory failure mandated VV ECMO support and extensive infectious workup for superadded infection. This resulted in positive markers of pulmonary blastomycosis reactivation and patient was started on prolonged anti-fungal therapy with amphotericin and steroid taper. Patient had prolonged critical care admission of over 60 days with slow clinical improvement. Despite of extensive post infection lung destruction from COVID and blastomycosis patient had slow recovery and was eventually weaned from ECMO support. Tracheostomy and extensive physical therapy for critical care myopathy resulted in successful transfer out of critical care unit to LTACH for further rehabilitation. DISCUSSION: Superadded fungal infections in COVID ARDS has been reported worldwide, particularly in patients requiring prolonged critical care admission and steroid therapy for organizing pneumonia. (1) While SARS-CoV-2-associated pulmonary aspergillosis (CAPA) has been the predominantfungal disease, other cases of disseminated candidiasis and a case report each of coccidiodomycosis and disseminated histoplasmosis have been reported. To our knowledge, this is the first reported case of pulmonary blastomycosis reactivation in COVID ARDS. (2) (3). While our patient had a extensive course in the critical care unit, her recovery was remarkable despite needing prolonged VV ECMO support for her COVID ARDS. CONCLUSIONS: To our knowledge, this is the first reported case of pulmonary blastomycosis reactivation in COVID ARDS. REFERENCE #1: White LPD, R.; Cordey, A.; Hughes, H.; Faggian, F.; Soni, S.; Pandey, M.; WHitaker, H.; May, A. A national strategy to diagnose COVID-19 associated invasive fungaldisease in the ICU. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. REFERENCE #2: Shah AS, Heidari A, Civelli VF, Sharma R, Clark CS, Munoz AD, et al. The coincidence of 2 epidemics, coccidioidomycosis and SARS-CoV-2: a case report external icon. J Investig Med High Impact Case Rep. 2020 Jun 4 REFERENCE #3: Bertolini M, Mutti MF, Barletta JA, et al. COVID-19 associated with AIDS-related disseminated histoplasmosis: a case report external icon. Int J STD AIDS. 2020 Sep 9 DISCLOSURES: No relevant relationships by Rabab Nasim, source=Web Response No relevant relationships by Hamad Nasim, source=Web Response No relevant relationships by Ankur Prasad, source=Web Response