Case Presentation: A 44-year-old male with a past medical history of psoriatic arthritis [on Guselkumab], asthma presented to the ED with worsening shortness of breath for 10 days and midsternal chest pain for 3 days. He tested positive for COVID-19 one week before and received monoclonal antibodies 2 days before presentation. He had COVID-19 infection 4 months ago but was asymptomatic. He was unvaccinated. He denied fevers, diarrhea, skin rashes. On presentation, he was afebrile, blood pressure 119/59mmHg, heart rate 77bpm, respiratory rate 20bpm, saturation 93% on 5 L nasal cannula. Over the course of the day, he developed worsening hypoxemia and was transferred to the ICU on a high flow nasal cannula (50LPM/95% FiO2). CT chest showed multifocal bilateral air space disease with tiny bilateral apical pneumothorax and extensive pneumomediastinum. The patient was started on Dexamethasone, Remdesivir, broad-spectrum antibiotics (Cefepime, Flagyl, Vancomycin, Azithromycin). His CRP was 17.8 mg/dL, but immunomodulators were held as the patient was at risk of fungal infections given that he was on Guselkumab. Over the course of the next 4 days, his respiratory status deteriorated to the point where he required ventilator support. For severe ARDS, he was sedated, paralyzed, and proned. He had persistent fever spikes with negative blood culture, sputum cultures. Bronchoalveolar lavage (BAL) cytology revealed fungal hypha and fungal culture grew Murcomyete (Lichthemia corymbifera). The patient was started on amphotericin B. CT sinus and ENT evaluation (nasal endoscopy) showed no evidence of invasive rhino-orbital disease. The patient continued to have persistent fevers (with negative repeat bacterial cultures), therefore Posaconazole was added as a combination therapy for mucormycosis and later changed to Isavuconazole based on sensitivities. His hospital course was complicated by shock requiring pressor support, acute tubular necrosis, metabolic acidosis requiring CRRT, right pneumothorax requiring chest tube placement. He also developed atrial fibrillation, bilateral lower extremity DVT requiring anticoagulation. He underwent tracheostomy and PEG tube placement and continues to require ventilator support. Based on Infectious Diseases recommendations, plan is to continue antifungal therapy for mucormycosis for a period of 6 months.
Discussion: COVID-19 is associated with a significant incidence of secondary infections, both bacterial and fungal probably due to immune dysregulation. Additionally, the widespread use of steroids, monoclonal antibodies, broad-spectrum antibiotics as part of the armamentarium against COVID-19 may lead to the development/exacerbation of preexisting fungal diseases. COVID-19 pneumonia with superimposed Aspergillus infection has been well-documented in literature. However, there is limited data on co-infection with Mucor in critically ill COVID-19 patients. Based on the site of infection and the patient’s underlying predisposing condition, the all-cause mortality rate of mucormycosis may reach up to about 80%, particularly in patients with central nervous system involvement.
Conclusions: Diagnosis of mucormycosis is difficult because it frequently requires invasive measures such as bronchoscopy. Clinicians should be aware of this risk in COVID pneumonia patients with persistent fever and hypoxemia. Therefore, it is important to have a high index of suspicion and a low threshold for fungal coinfection in patients with COVID-19 infection.
