Case Presentation: An 88-year-old male presented to the emergency department (ED) for dyspnea. Of note, patient is from nursing home (NH) and history was obtained from nurse (RN). RN notes that he was at baseline, talkative and pleasant. He had tested positive for COVID as NH had outbreak, and then weakened over a few days. One morning, RN heard him gurgling from his room, went to suction him, and saw his oxygen saturation was getting low despite supplemental O2. He was sent to the ED for further evaluation. He was noted to have a cough. He was unable to communicate but was responding to commands. His vital signs were stable. On physical exam rhonchorous breath sounds were heard throughout all lung fields and copious thick yellow secretions were noted. Initial work up was significant for anemia, leukopenia, thrombocytopenia, hyperkalemia, elevated procalcitonin to 0.76 ng/mL, and COVID-19 positive. Of note patient was found to be in respiratory distress and it was decided to intubate in the ED. Patient was started on Cefiderocol, Norepinephrine, and Propofol. His sputum cultures grew Acinetobacter baumannii multidrug resistant organisms (MDRO) and patient was deemed to have MDRO pneumonia. Interestingly his blood cultures grew Saccharomyces Cerevisiae and patient was appropriately started on Micafungin. CT chest, abdomen, and pelvis showed his PEG tube, (placed on previous admission), transverses the distal transverse colon before entering the stomach. Interestingly, the patient has been receiving tube feeds for the past ten days with no issues. General surgery stated patient’s PEG can be repositioned electively or emergently if patient was to decompensate. Patient was successfully weaned off pressors. However, he failed spontaneous breathing trial several times as he became apneic and unable to clear secretions. Eventually he was able to be extubated and was transferred to floors for further management to only be upgraded back to ICU after cardiac arrest.
Discussion: Saccharomyces cerevisiae is an ascomycetes yeast, historically used to ferment sugars to produce varieties of food and beverages, and more recently as an ingredient in probiotic supplements. Predisposing risk factors for invasive Saccharomyces infection include, indwelling center catheters, total parenteral nutrition, ICU admission, antibiotic use, and immunosuppression. Invasive infection is thought to be mainly through the invasion of the digestive tract and the colonization of central venous catheters. It has been suggested that adhesins proteins play a role in allowing Saccharomyces cerevisiae to cross compromised epithelial borders. Thus, the most likely source of our patient having fungemia is the PEG tube inappropriately going through the distal transverse colon before entering the stomach. Patient’s nursing home medication list was reviewed, and no probiotics can be identified. The mainstay of therapy is the withdrawal of probiotic supplements, if taken, the removal of catheters, and the administration of antifungal agents.
Conclusions: Saccharomyces cerevisiae fungemia is a rare entity to encounter during clinical practice. Therefore, physicians should be able to identify predisposing risk factors for invasive Saccharomyces infection for prompt diagnosis and therapeutic management. It is also essential to ask about the patient’s probiotic use, as it can cause fungemia in severely ill and immunocompromised patients.
