A 55-year-old Caucasian woman was admitted to our Hospital after a two-day history of fever (38.5 C) and acute dyspnea with severe respiratory distress and room-air oxygen saturation of 70% occurring few hours after the administration of chemoimmunotherapy.
The patient was diagnosed with a triple negative, BRCA1-related, PD-L1 positive right breast cancer four years earlier and was treated with quadrantectomy, radiotherapy and adriamycin-cyclophosphamide and docetaxel-based adjuvant chemotherapy.
The tumor had spread with multiple bone metastasis -skull, vertebral, sternum, scapula, ribs, and femurs- and caused bone marrow infiltration-related severe pancytopenia. She was treated with atezolizumab and nab-paclitaxel as first line chemotherapy.
She suspended, two weeks before, the self-administration of Ganoderma lucidum medicinal mushrooms as an anticancer supplement.
Patient recently received flu vaccination and her remaining medical history comprised chemical diabetes.
The physical examination revealed Glascow Coma Scale 14, body temperature 37.7 C, blood pressure 105/60 mmHg, heart rate 117 beats/minute, respiratory rate 25 breaths/minute, oxygen saturation 90% while receiving a 100% fraction of inspired oxygen (FiO2) on reservoir mask -pH 7.55; pCO2 30 mmHg; pO2 87 mmHg, arterial bicarbonate level of 27.5 mmol/L, arterial lactated level of 21, partial pressure of oxygen (pO2)/FiO2 87 mmHg (stage III Acute Respiratory Distress Syndrome)- BMI 30 kg/m2. Chest examination showed scattered wheezes, rales, and bilateral dry crackles in the middle and lower lung fields; regular cardiac rhythm with paraphonic cardiac sounds. Neurological examination revealed lower limb paresis.
Laboratory tests results included hemoglobin of 6.7 g/dL, hematocrit of 20.2%, platelet count of 18,000/microL, white blood cells of 2210/microL -neutrophil and lymphocytic count of 1720 (77%) and 440/microL (19.9%), respectively- erythrocyte sedimentation rate of 76 mm/h, C-reactive protein of 43.06 mg/dL, procalcitonin of 0.55 ng/dL, and albumin of 2.6 g/dL.
The microbiological sample results for Chlamydia pneumoniae, Mycoplasma pneumoniae, Respiratory Syncytial, Adenoviruses, Coxsackieviruses, Influenza A and B viruses turned out negative, as well as the nasopharyngeal swab for SARS-CoV2. Further tests included negative Streptococcus pneumoniae and Legionella pneumophila urinary antigens, serum galactomannan assay, beta D-glucan assay, immunofluorescence assay for the detection of Pneumocystis jirovecii and blood culture. Quantiferon TB Gold test resulted indeterminate, and Staphylococcus aureus was isolated from endotracheal aspirate.
The chest computed tomography (CT) scan showed the presence of large areas of parenchymal consolidation with aerial bronchogram, bilateral "ground glass" areas reaching the highest extension on the upper and middle zones, and a moderate bilateral pleural effusion. Nonspecific sub-centimetric ilo-mediastinal lymph nodes and several metastatic lytic bone lesions were also revealed (Figure 1A-C). The artificial intelligence software (CT deep learning algorithm) estimated a positive predictive value of 64% for COVID-1-related pneumonia.
The chest physical examination was suggestive for interstitial pneumonia that was confirmed by the CT scan. Furthermore, based on current epidemiology, the oncologic patient's frailty suggested the need for an endotracheal aspirate detecting spike protein (S) and envelope (E) genes for SARS-CoV2 molecular test that resulted positive (Figure 2A).
The bilateral lung consolidation along with the interstitial radiologic pattern and the recent history of G. lucidum administration questioned the real nature of the pneumonia.
However, to date, no data are available on fungal pneumonia due to G. lucidum administration.
The patient started an empiric antimicrobial treatment with vancomycin 2 g/day, meropenem 3 g/day, and levofloxacin 500 mg/day along with amphotericin B therapy (loading dose of 6 mg/kg bid, followed by 300 mg bid) and high flow oxygen supplementation (FiO2100%).
Otherwise, the endotracheal aspirates showed positive results for SARS-CoV2 and for methicillin-sensible S. aureus. Antimicrobial therapy was, therefore, de-escalated and lopinavir-ritonavir plus hydroxychloroquine therapy was started. Unfortunately, the patient died five days after hospital admission.