Case Presentation: A 56-year-old male with a past medical history of large B cell lymphoma on ibrutinib with recently diagnosed COVID pneumonia, and recurrent ascites due to portal hypertension, presented to the hospital due to shortness of breath, and fever for one week. Physical examination was unremarkable on admission except for fever. His initial labs were significant for leukopenia and elevated inflammatory markers. Chest x-ray showed interstitial opacities in the right lung. Initial treatment included ceftriaxone, azithromycin, Remdesivir and dexamethasone. He was placed on HFNC which was eventually escalated to endotracheal intubation due to worsening hypoxia. His blood culture, peritoneal fluid, and serial sputum cultures tested positive for burkholderia cepacia. He was initially treated with ceftazidime and levofloxacin, but despite the organism being sensitive to both medications, the patient continued to grow burkholderia cepacia in sputum culture. Inhaled tobramycin was eventually added but his cultures remained positive, and his condition kept deteriorating. In light of clinical deterioration, and guarded prognosis, the family opted for comfort measures and he was extubated compassionately.

Discussion: Burkholderia Cepacia (B. cepacia) is a group of aerobic gram-negative rods mainly found in cystic fibrosis and occasionally in patients with chronic granulomatous disease. After a thorough literature review we found only a handful of cases of B cepacia that have been reported in patients admitted with COVID 19. Identification of B cepacia coexistence with COVID 19 in immunocompromised patients is important since it significantly worsens the outcome of COVID 19. A study done in Guangdong Province, China on the characterization of respiratory microbial dysbiosis in hospitalized COVID-19 patients found B Cepacia to be the most commonly found bacteria. Early determination of its presence by sending sputum cultures, and determination of antimicrobial susceptibility is very crucial since extensive antimicrobial resistance has been observed in the past. In our case the patient was put on multiple antimicrobials that he was susceptible to but his cultures still kept growing B. cepacia which ultimately led to a poor outcome.

Conclusions: Early diagnosis of B. cepacia superinfection in patients hospitalized with COVID – 19 pneumonia is crucial. Aggressive treatment with polymicrobial therapy with two or more antibiotics is recommended to increase the probability of survival.

IMAGE 1: CT chest without contrast showing dense consolidation with widespread ground-glass attenuation