Submitted by: M. Hong Nguyen, MD
Institution: University of Pittsburgh
Chief Complaint: fever and shortness of breath
56-year-old man was admitted to an outside hospital with fever, short of breath and hypoxia. COVID-19 was diagnosed in the emergency room. He was treated with remdesivir and dexamethasone along with ceftriaxone and azithromycin.
Day 7: He developed acute respiratory distress syndrome requiring intubation. Dexamethasone was continued
Day 9: Due to refractory hypoxemia, he was transferred to our hospital for further management.
Coronary artery disease with history of cardiac arrest 2016
History of ventricular fibrillation, status post AICD
Surgical/invasive procedure Hx:
CABG X4 over 10 years ago
Stent placement in 2019
Coronary artery disease and cerebrovascular accident
Lives in Huntingdon, PA
Tobacco: previous 3 pack per day for 18 years. Quit 2016
Review of Symptoms:
Unobtainable due to sedation and paralysis
MEDICATIONS – on transfer
Vital Signs: T 37.5 C, HR 98 bpm, RR 10 breaths/minute, BP 98/42 mmHg
General: Intubated, unresponsive
Cardio: Rate irregularly irregular, no murmur
Pulmonary: Coarse breath sounds throughout. Decreased breath sounds both bases
Abdomen: Bowel sounds present, non-distended, soft
Extremities: 1+ ankle edema
Skin: No rashes
Creatinine 1.2 mg/dL
AST 27 U/L
ALT 27 U/L
Alk Phos 60 U/L
Total bili 0.6 mg/dL
LDH 753 U/L
WBC 16.1 x109/L (97% PMN, 1% lymph, 2% mono)
Ferritin 753 ng/mL
Lactate 2.6 mmol/L
Baseline Chest X Ray (on transfer)
Timeline of Hospital Course:
Day 9 (day of transfer): Bronchoscopy showed friable airways and thick mucus in both lower lobes. He was started on piperacillin-tazobactam. Dexamethasone was stopped
-BAL culture grew 50,000 CFU/mL Chryseobacterium indologenes
Day 10: He was placed on veno-venous extracorporeal membrane oxygenation (ECMO)
Day 12: Leukocytosis resolved (WBC down to 8)
Day 14: Renal function progressively worsened.
Day 17: Creatinine peaked to 4.4 . Urine output was marginal, unresponsive to furosemide
Day 18: Patient was started on continuous renal replacement therapy, but became hypotensive requiring low dose norepinephrine (1 mcg/kg/min) for fluid removal.
Blood and BAL cultures were unrevealing. As per UPMC protocol, surveillance fungal biomarkers with BDG and GM were obtained. BAL culture grew <5.000 CFU/mL Gram negative rods; fungal culture was negative.
BDG = 40 pg/mL
Serum GM = 3.23
BAL GM= 9.04
Day 20: Results of GM prompted CT chest cavitary lung lesion RUL. Patient was started on voriconazole and caspofungin. Bronchoscopy did not show a large amount of secretions. BAL fungal culture: no growth
Day 23: Patient suffered two episodes of cardiac arrest. Family decided to make him comfort measure only
IMAGES (CAT scan of chest Day 18) – diffuse areas of ground glass opacities and traction bronchiectasis involving all lobes, and air bronchograms. There was a 3.3 x 2.7 cm cavitary lesion within the right upper lobe
AUTOPSY: The lungs were severely congested with diffuse hemorrphage and parenchymal consolidations. There was a 2.5 x 2.0 x 2.0 cm tan-brown, cavitary lesion in the right upper lobe. Microscopic sections showed extensive invasive branching hyphal structures, acute inflammation, and necrosis.
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