A TALE OF TWO SPECIES: FIRST REPORTED CASE OF AN EMPYEMA SECONDARY TO CO-INFECTION WITH SARS-COV-2 AND CANDIDA ALBICANS

Sharma, Aniket; Mehta, Neha; Pirrotta, Stefania; Sheldon, Drew; Juarez, Ricardo

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Since the start of the COVID-19 pandemic, the scientific community has been tasked with describing the pathophysiology and clinical findings of this novel disease to enhance treatment. There have been few reports of pleural effusions associated with COVID-19 infection, however none have been associated with fungal empyema. We present a case of COVID-19 isolated in a Candida albicans (C. albicans) empyema. CASE PRESENTATION: A 55 year old male with hypertension presented to an outside hospital with shortness of breath. He was SARS-CoV-2 (SCV-2) positive and developed progressive respiratory failure requiring intubation on hospital day five. Respiratory culture at time of intubation demonstrated co-infection with MRSA which was treated appropriately. Due to ongoing respiratory failure, he was transferred to our facility for higher level of care on hospital day 17. On arrival, chest x-ray demonstrated diffuse airspace disease with bilateral effusions and nasal swab remained positive for SCV-2. Bronchoscopy was performed and only C. albicans was isolated in bronchoalveolar lavage. Bedside ultrasonography demonstrated a loculated right sided pleural effusion (Fig1,2). Tube thoracostomy and pleural fluid analysis revealed a neutrophil-predominant, exudative effusion consistent with empyema. Pleural fluid PCR was positive for SCV-2 and fungal culture grew C. albicans, suggesting concomitant viral and fungal parapneumonic effusions. Pleural fluid drainage as well as initiation of micafungin resulted in an initial improvement in leukocytosis (Fig 3). Left pleural effusion increased in size and left tube thoracostomy side also revealed C. albicans and SCV-2 positive PCR. DISCUSSION: The incidence of pleural effusions from COVID-19 pneumonia is unknown, but reports suggest a range of 5-9% (1,2). Empyema secondary to Candida are more rare and associated with mortality rates as high as 73% (3). The significance of COVID-19 in pleural fluid remains unclear, but may have led to this manifestation of fungal pneumonia as fungal empyemas are most common in patients with severe underlying illnesses or malignancies. We hypothesize that peripheral opacities in COVID-19 infection may result in infiltration of the pleura, increasing the risk of complicated parapneumonic effusions. The patient currently remains intubated and has been unable to resolve his empyema which remains both SCV-2 and Candida positive. CONCLUSIONS: The risk factors and significance of SCV-2 associated pleural effusion remain unknown. We present the first reported case of a patient with bilateral effusions positive for co-infection with SCV-2 and C. albicans. Further studies are required to elucidate the mechanism that allowed for a previously immunocompetent SCV-2 positive host to develop a co-infection with C. albicans. Reference #1: Zhou S, Wang Y, Zhu T, Xia L. CT Features of Coronavirus Disease 2019 (COVID-19) Pneumonia in 62 Patients in Wuhan, China. AJR Am J Roentgenol. 2020;214(6):1287-1294. doi:10.2214/AJR.20.22975 Reference #2: Shi, Heshui, et al. "Radiological Findings From 81 Patients With COVID-19 Pneumonia in Wuhan, China: a Descriptive Study." The Lancet. Infectious Diseases, vol. 20, no. 4, 2020, pp. 425-434. Reference #3: Williams J, Lanfranco OA, Lemos-Ramirez J, Bhargava P, Alangaden G, Ramesh M. Epidemiology, Risk Factors and Outcomes of Candida Empyema: A 5-Year Single-Centered Experience. Open Forum Infect Dis. 2017;4(Suppl 1):S88. Published 2017 Oct 4. doi:10.1093/ofid/ofx163.046 DISCLOSURES: No relevant relationships by Ricardo Juarez, source=Web Response No relevant relationships by Neha Mehta, source=Web Response No relevant relationships by Stefania Pirrotta, source=Web Response No relevant relationships by Aniket Sharma, source=Web Response No relevant relationships by Drew Sheldon, source=Web Response