PULMONARY CRYPTOCOCCOSIS COMPLICATING POST-COVID-19 PULMONARY FIBROSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary cryptococcosis (PC) is an opportunistic invasive mycosis common in immunocompromised patients, presenting as dyspnea and cough(1). Studies have shown opportunistic infections such as pulmonary aspergillosis, candida and pneumocystis pneumonia in critically ill patients with COVID-19. However data on incidence of PC in this subset of patients is sparse(2). We discuss a patient with post-COVID-19 pulmonary fibrosis(PF) who developed PC. CASE PRESENTATION: A 62-year-old lifelong non-smoker male presented with worsening dyspnea and cough. One month prior to this, he was treated for new hypoxic respiratory failure secondary to COVID-19 pneumonia and pulmonary embolism and was on baseline oxygen therapy 4L/min since. On presentation, he was noted to be afebrile, tachycardic HR of 114/min, tachypneic with RR 24/min, and saturating 93% on 6L O2. He had bilateral crackles on chest auscultation. Initial labs were unremarkable except ABG showing normal pH of 7.38, with hypoxia pO2 58 and hypercarbia pCo2 65. COVID-19 PCR remained positive. Chest X-ray was suggestive of multifocal pneumonia. Chest CT revealed severe multifocal pneumonia with interval development of bronchiectasis. Patient was initiated on IV linezolid, meropenem, remdesivir and dexamethasone;he required BiPAP support due to respiratory failure. Worsening respiratory failure despite completion of antibiotic course, prompted initiation of ceftazidime. He was also started on trial of IV methylprednisolone 125mg every six hourly in view of suspected post-COVID-19 PF, administered for two weeks. Patient's hospitalization was further complicated by critical illness myopathy, atrial fibrillation and flutter. Subsequently fungal serology returned positive for cryptococcal antigen and fluconazole therapy was initiated. He had no history of immunocompromise such as HIV, Diabetes, ESRF etc. CSF analysis was deferred since he had no CNS manifestations. Patient showed clinical improvement into second week of hospitalization and repeat CT scan done 18 days after starting fluconazole showed interval improvement of multifocal infiltrate. DISCUSSION: Post-COVID-19 pulmonary fibrosis is increasingly identified with evolving clinical data. Dysregulated release of matrix metalloproteinases, epithelial injury, and fibroproliferation are all implicated in the pathogenesis of post infective PF(3). CONCLUSIONS: High dose steroids used in the management of PF pose serious risk of complications related to immunosuppression and subsequent opportunistic infections such as pulmonary cryptococcosis and pneumocystis pneumonia. As the pandemic is still evolving, it will be interesting to see if PF and opportunistic infections become an established post-COVID-19 sequela. REFERENCE #1: Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol. 2019 Feb 1;57(2):133-150. doi: 10.1093/mmy/myy086. PMID: 30329097. REFERENCE #2: Salehi M, Ahmadikia K, Badali H, Khodavaisy S. Opportunistic Fungal Infections in the Epidemic Area of COVID-19-19: A Clinical and Diagnostic Perspective from Iran. Mycopathologia. 2020;185(4):607-611. doi:10.1007/s11046-020-00472-7 REFERENCE #3: Tale S, Ghosh S, Meitei SP, Kolli M, Garbhapu AK, Pudi S. Post-COVID-19-19 pneumonia pulmonary fibrosis. QJM. 2020;113(11):837-838. doi:10.1093/qjmed/hcaa255 DISCLOSURES: No relevant relationships by Sangeetha Isaac, source=Web Response No relevant relationships by Shalom Isaac, source=Web Response No relevant relationships by Evans Kyei-Nimako, source=Admin input No relevant relationships by Amos Lal, source=Web Response No relevant relationships by Mohammed Afraz Pasha, source=Web Response