A 71-year-old man with a history of hypertension and type 2 diabetes was admitted to our hospital with a diagnosis of COVID-19 pneumonia from a private care facility. The patient was transferred to our hospital after a 48-hour admission to the emergency department of another hospital, where tocilizumab (maximum dose 800 mg) and corticosteroid (4 mg every 6 hours) were administered.
An initial COVID-19 real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 was performed using a throat swab, which showed a positive result for SARS-CoV-2. The patient had received no COVID-19 vaccine because it was not available in our country at the time of presentation of this case.
On arrival, he presented with signs of hypoxemic respiratory insufficiency and showed pulmonary involvement by COVID-19 based on typical computed tomography (CT) findings (COVID-19 Reporting and Data System [CO-RADS] 5-6). Therefore, the patient was intubated, with an arterial oxygen partial pressure (PaO2)/fractional inspired oxygen (FIO2) ratio of 120 prior to intubation, and mechanical ventilation was initiated.
Serum tests revealed leukocytosis: 29.000 k/uL, lymphopenia: 0.40 K/uL, C-reactive protein: 44 mg/L, interleukin-6 (IL-6): 4365 pg/mL, ferritin: >2000 ng/mL, D-dimer: 6520 ng/mL, lactate dehydrogenase (LDH): 785 U/L, and creatinine: 2.1 mg/dL. Culture samples were taken and empiric antibiotic therapy was started with imipenem and levofloxacin. After a few days of hospitalization, the patient's renal function deteriorated and, therefore, four hemofiltration sessions were prescribed. Chest radiography (CXR) revealed the presence of a cavitary image in the right upper lobe.
On day 7, the hemoculture and urine culture results showed no bacterial growth; however, the patient's clinical condition did not improve. Broad-spectrum antibiotics, meropenem, vancomycin, and the antifungal fluconazole, were prescribed. In addition, a bronchoscopy procedure was performed, which revealed erythematous lesions in the bronchial tree, abundant purulent secretions, and a cavitary lesion mainly in the right bronchial tree (Picture 1).
Bronchoalveolar lavage (BAL) revealed erythematous lesions in the bronchial tree, abundant purulent secretions, and a cavitary lesion, mainly in the right bronchial tree.
The BAL samples isolated Klebsiella pneumoniae and Pseudomonas aeruginosa carbapenemase class A. Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) Biotyper mass spectrometry, molecular biology methods, multiplex PCR, and molecular identification were performed. The right BAL fungal culture isolated Trichosporon asahii (Picture 2A and B). The BAL sample was negative for both Ziehl Neelsen (ZN) stain and GeneXpert mycobacterium tuberculosis (MTB)/rifampicin (RIF; Xpert), and the Lowenstein-Jensen culture for tuberculosis was also negative.
Ceftazidime/avibactam, colistin, and voriconazole were administered. Despite all the efforts, the patient presented with disease progression, septic shock, and multi-organ failure, and died after 15 days of hospitalization. (See the time lines in Table 1).
Unfortunately, the evolutionary chest CT was not performed in this patient because the equipment was under technical maintenance due to excessive demand during the pandemic. However, disseminated opacities were observed in all lung quadrants, indicative of severe CARDS (Picture 3).