UNEXPECTED OPPORTUNISTIC INFECTION IN PATIENT WITH SEVERE COVID-19 PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: The pathogenesis of the novel coronavirus, Covid-19, was characterized by an overdrive of the immune system that lead to some patients to a life-threatening cytokine storm with severe lung inflammation and multiorgan failure. Considering this pathogenic pathway, the use of high dose systemic steroids, and other immunomodulatory therapy was part of the main therapy. As management evolves, complications have risen, including cardiac, thromboembolic, neurologic and secondary infections. Multiple clinical reports have described complications with bacteria, and fungal infections in different organ systems, most commonly the respiratory track. However, systemic and multiorgan infections have been reported due to severe immunosuppression after viral infection and the use of anti-inflammatory therapy. CASE PRESENTATION: We present the case of an 86-year-old male with a past medical history of benign prostate hypertrophy, hyperlipidemia and hypertension who developed respiratory failure due to severe COVID-19 pneumonia, managed with antiviral therapy and high dose dexamethasone. After initial improvement from the respiratory standpoint, the patient developed persistent fungemia with Candida parapsilosis. There was no evidence of endocarditis. The patient presented with persistent altered mental status after cessation of sedation. Brain imaging revealed a right posterior parietal parafalcine hematoma with surrounding vasogenic edema. Angiogram revealed a saccular aneurysm measuring approximately 5.7 mm in largest dimension located at midline posterior frontal in location in relation to pericallosal arteries. Cerebral arterial aneurysm secondary to systemic fungal infection, knowns as mycotic aneurysms, have been reported in medical literature. DISCUSSION: Aneurysms are an abnormal arterial focal dilation which can become infected, but also aneurysmal degeneration of the arterial wall can occur due to bacteremia or a septic embolus;as seen in mycotic aneurisms. Despite its name, most mycotic aneurysms are caused by bacteria from associated endocarditis. This is a serious complication associated to an elevated morbidity and mortality. Several risk factors predispose to infected aneurysm, these include arterial injury, infection, immunocompromised status, atherosclerosis and pre-existing aneurysms. Fungal infections tend to be rare but may occur in immune suppressed patients or as sequelae of treatment of disseminated fungal disease. CONCLUSIONS: This is an unexpected complication of immunosuppression with systemic steroids in management of COVID-19 pneumonia. Treatment with systemic steroid and thromboembolic complication prevention have helped improve COVID-19 pneumonia patient prognosis, however physicians should be careful as it predisposes patients, especially those with advanced age, to opportunistic infections in unexpected organ and settings. REFERENCE #1: WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group, Sterne JAC, Murthy S, Diaz JV, Slutsky AS, Villar J, Angus DC, Annane D, Azevedo LCP, Berwanger O, Cavalcanti AB, Dequin PF, Du B, Emberson J, Fisher D, Giraudeau B, Gordon AC, Granholm A, Green C, Haynes R, Heming N, Higgins JPT, Horby P, Juni P, Landray MJ, Le Gouge A, Leclerc M, Lim WS, Machado FR, McArthur C, Meziani F, Moller MH, Perner A, Petersen MW, Savovic J, Tomazini B, Veiga VC, Webb S, Marshall JC. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. JAMA. 2020 Oct 6;324(13):1330-1341. doi: 10.1001/jama.2020.17023. PMID: 32876694;PMCID: PMC7489434. REFERENCE #2: Wu FZ, Lai PH. Evolution and regression of intracranial infectious aneurysm diagnosed by brain computed tomographic angiography. Arch Neurol. 2010 Sep;67(9):1147. doi: 10.1001/archneurol.2010.216. PMID: 20837863. REFERENCE #3: World Health Organization. Corticosteroids for COVID-19: Living guidance. https://www.who.int/publications/i/item/WHO-2019-nCoV-Cor icosteroids-2020.1 DISCLOSURES: No relevant relationships by Onix Cantres-Fonseca, source=Web Response No relevant relationships by Porfirio Diaz-Rodriguez, source=Web Response No relevant relationships by Hector Nieves, source=Web Response No relevant relationships by Luis Vazquez, source=Web Response