Invasive fusariosis in a critically ill patient with severe COVID-19 pneumonia from Argentina.

BARBERIS F; BENEDETTI, MARÍA FERNANDA; DE ABREU MS; POLA SJ; POSSE GB; CAPECE P; FERNANDEZ LAUSI A; TOSCANINI MA; NUSBLAT AD; CUESTAS ML

Congreso; 19TH INFOCUS.; 2021

Objectives: Invasive fungal infections as aspergillosis and candidiasis are well-documented complications in critically ill patients with acute respiratory distress syndrome due to COVID-19. However, invasive infections by other molds were rarely reported. We describe a fatal case of invasive fusariosis in an immunocompetent patient in Argentina who had severe coronavirus disease-associated pneumonia.Methods: A 68-year-old man with obesity as the only underlying disease was admitted to the intensive care unit (ICU) at Posadas Hospital with signs of acute respiratory failure. He received broad spectrum antibiotics due to ventilator-associated bacterial pneumonia. After 39 days of admission at ICU a tracheostomy was placed as a result of prolonged ventilation, acute respiratory distress syndrome and sepsis. He presented multiple injuries due to prone position at the facial level, lower limbs and a sacral eschar grade III without local signs of infection. He also presented bilateral nail hyperkeratosis lesions on both feet. On HD 69, one out of two BacT/ALERT FAN aerobic blood culture bottles yielded Fusarium spp., whose hyphae were observed on Gram-stained smears. These fungal isolates were identified as Fusarium verticillioides using Matrix Assisted Laser Desorption/Ionization Time-Of-Flight (MALDI-TOF) mass spectrometry (VITEK® MS, bioMérieux). Antifungal therapy with sodium deoxycholate amphotericin B (1 mg/kg/day) and intravenous voriconazole (400 mg/12 h first day, then 200 mg/12 h) was then started. After 80 days of hospitalization, the patient died due to respiratory instability, sepsis and shock, despite clearance of fungemia burden during antifungal therapy. Results: Herein we described the first fatal case of invasive fusariosis due to F. verticillioides in an immunocompetent patient with severe COVID-19. Before the advent of voriconazole, lipid-based formulations of amphotericin B were the first line therapy for invasive fusariosis. Since FDA approval, voriconazole is the treatment of choice for the vast majority of Fusarium species. Combination therapy with amphotericin B and voriconazole against invasive fusariosis was also described and it seems to be a good strategy when Fusarium species are still being identified. In this case report, it should be mentioned that despite the negativization of fungemia during antifungal therapy, the patient died in the ICU while receiving this treatment, due to unfavourable outcome (respiratory instability and septic shock by another catheter-related infection).Conclusion: Sharing experiences and information about fungal superinfections in critically ill patients with severe COVID-19, make clinicians and mycologists to suspect fungal invasive infections and thus to prevent to arrive late at diagnosis. Finally, severe COVID-19 disease taught us to think about another fungal infections not previously present in immunocompetent patients.