Case Presentation
A 60-year-old man with a history of hypertension, diabetes mellitus, and
ischemic heart disease admitted to the intensive care unit (ICU) with
confirmed COVID-19 infection required mechanical ventilation; on the
same day of admission, he was pronned for many times due to low
PaO2/FiO2 (P/F) Ratio. He received 3 doses of tocilizumab (400mg/once),
(600mg/once) and (600mg/once) respectively due to possible cytokine
storm; he received several doses of methylprednisolone as part of the
COVID-19 management and hydrocortisone.
Few days after receiving tocilizumab, his bronchial alveolar lavage was
positive for Candida glabrate ; he was started on anidulafungin
200mg q 24hr for 7 days. The patient was sedated and intubated for 22
days, so a tracheostomy was done. He developed acute kidney injury (AKI)
after 28 days of ICU admission hence hemodialysis started.
Despite that the patient was on antibiotics, his inflammatory marker is
still high. Thus, full septic workups were done, and the patient was
having candidemia (Candida parapsilosis ) after one month of the
admission. For which he was started on
anidulafungin 200mg q 24hr for
more than 7 days. Many episodes of gastrointestinal (GI) tract bleeding
complicated his course manifested as melena and per rectal bleeding, but
all the episodes were managed conservatively by the gastroenterology
team. The candidemia persists after 2 weeks of treatment and there was
an increase in C-reactive protein (CRP) level despite that the patient
was under antibiotic and antifungal cover. Hence, the ID team
recommended giving antifungal (anidulafungin 100mg) for a total of 14
days to involve an ophthalmologist to rule out fungal ophthalmitis.
Still, it was not applicable and to do an echocardiogram to rule out
vegetation and it was ruled out by trans-thoracic echocardiogram.
While the patient was on anidulafungin, his blood culture became
positive for Cryptococcus neoformans after 18 days of receiving
anidulafungin for previous candida infection, for which he was started
on amphotericin (300mg, q24hr) and flucytosine (500mg q12hr). And there
was a recommendation from the ID team to do trans esophageal echo and
lumbar puncture to rule out vegetation and brain involvement,
respectively, but both tests were not done due to poor prognosis and
risk of bleeding because the patient had thrombocytopenia (platelet 21,
RR=150 - 400 × 109/L). The Cryptococcemia persist
despite the management and he developed sepsis and die within 10 days of
the Cryptococcemia.