LAUSR

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 has been associated with a variety of clinical presentations, secondary infections, and sequelae. A growing number of case reports suggest COVID-19 may be associated with increased risk of fungal infections, including fungemia and meningitis. CASE PRESENTATION: A 66-year-old Hispanic man with liver cirrhosis, type 2 diabetes mellitus, and obesity presented to a critical access hospital with complaints of hematemesis. He was evaluated by gastroenterology and found to have gastritis. The next day he developed hypoxia and was found to have COVID-19 pneumonia. He was supported briefly on non-invasive ventilation, but ultimately needed intubation and mechanical ventilation. He received Remdesivir and high dose Dexamethasone protocol (20mg for 5 days, followed by 10mg for 5 days), as well as lung protective ventilation.On hospital day 22, he developed altered mental status. A chest x-ray revealed worsening bilateral infiltrates suspicious for bacterial pneumonia. Blood cultures subsequently grew Cryptococcus neoformans. He was initiated on Amphotericin, Flucytosine, and Meropenem, resulting in worsening acute kidney injury. A lumbar puncture was performed and revealed an opening pressure of 40cm, glucose 142mg/dL, protein 38mg, and no nucleated cells. CSF culture grew Cryptococcus neoformans, confirming the diagnosis of disseminated Cryptococcal infection.A full immune work up, including HIV, was conducted, none of which was revealing. Despite maximal therapy, the patient developed worsening liver and renal failure. His family pursued comfort measures and he was pronounced deceased on hospital day 33. DISCUSSION: COVID-19 presents many unique and challenging scenarios. Notably, lymphopenia is a consistent laboratory finding. Research suggests lymphopenia may be secondary to the cytokine storm found in COVID2. Other postulations include infection of lymphocytes and increased PDL-1 expression(2). Lymphopenia and other immunocompromised states increase risk of fungal infections. Prolonged or high dose steroid use also increases risk of fungal infections, in part due to suppression of T lymphocytes. Disseminated Cryptococcus is uncommon in HIV-uninfected patients. Most case reports reveal underlying conditions such as poorly controlled type 2 diabetes or liver cirrhosis(1). This patient presents an interesting interplay of chronic conditions, acute COVID-19 infection, and high dose steroid use, any combination of which could lead to disseminated Cryptococcal fungemia. CONCLUSIONS: As we continue to understand more about the pathology and treatment of COVID-19, careful consideration should be given to causative mechanisms for opportunistic fungal infections to avoid additional morbidity and mortality. REFERENCE #1: Chuang, Y. M., Ho, Y. C., Chang, H. T., Yu, C. J., Yang, P. C., & Hsueh, P. R. (2008). Disseminated cryptococcosis in HIV-uninfected patients. European Journal of Clinical Microbiology & Infectious Diseases, 27(4), 307-310. REFERENCE #2: Lionakis, M. S., MD, & Kontoyiannis, D. P., MD. (2003). Glucocorticoids and invasive fungal infections. The Lancet, 362(9398), 1828-1838. DISCLOSURES: No relevant relationships by Jeffrey Macaraeg, source=Web Response No relevant relationships by Anna Plemmons, source=Web Response No relevant relationships by William Pruett, source=Web Response