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.