A REPORT OF FUNGAL EMPYEMA FOLLOWING RECOVERY OF SEVERE SARS-COV-2 INFECTION

Glendening, Joseph; Koroscil, Matthew

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The COVID-19 pandemic represents the rapid spread of a condition challenging how medicine responds to a novel disease as well as our understanding of typical presentations of disease states. Fungal empyema is a rare complication of critical illness. Cases are most often nosocomial and associated with high mortality. We report the first documented case of fungal empyema associated with SARS-CoV-2 infection. CASE PRESENTATION: A 73-year-old man with a history of congestive heart failure and type-2 diabetes, presented to the Emergency Department (ED) with respiratory failure and septic shock, about one week after he was diagnosed with atypical pneumonia. His nasopharyngeal wash for SARS-CoV-19 returned positive several days after first ED visit. The patient was intubated and started on antibiotics and hydroxychloroquine. He was extubated after 4 days of low-tidal volume ventilation per ARDSNet protocol. He had a prolonged hospital stay complicated by Moraxella bacteremia and was discharged after 21 days. He was readmitted with a chest CT notable for bilateral pulmonary emboli, extensive bilateral pneumonia, and a loculated pleural effusion. He was started on heparin and antibiotics. A chest tube was placed, and pleural fluid studies were notable for an exudative effusion. Pleural cultures obtained grew Candida albicans, which was initially thought to be a possible contaminant;however repeat pleural cultures continued to exhibit C. albicans as did a sputum culture. His WBC count and CRP continued to elevate despite pleural drainage and antibiotics, and he was transferred for a video-assisted thoracoscopic surgery (VATS) evaluation. Fluconazole was initiated. Patient had clinical improvement with fluconazole and continued chest tube drainage, so he did not undergo VATS. He was discharged on oral antimicrobials and apixaban. DISCUSSION: This is the first described case of fungal empyema secondary to COVID-19. Fungal empyema represents less than <1% pleural infections with C. albicans being the most common pathogen. Overall mortality is as high as 73%, and most patients are critically ill. Patients should have prompt chest tube drainage, and in cases of failure with rising CRP or persistent sepsis, early thoracic surgery consultation is appropriate as evidenced by two small studies (n=20 and 70) where early VATS vs. chest tube resulted in decreased hospital stay and rates of treatment failure. CONCLUSION(S): Clinicians should consider fungal empyema in recovered COVID-19 patients presenting with a complicated pleural space. Chest tube drainage and IV antifungal coverage are effective initial therapies along with early evaluation for possible VATS. Reference #1: Davies HE, Davies RJO, Davies CWH. Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:ii41-53. Reference #2: Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis. CHEST. 117(6):1672-8 Reference #3: 3. Pestana Caires N, Campos Silva S, Eurico Reis J, et al. Fungal empyema: an uncommon disease with high mortality. European Respiratory Journal. 2019 Sep;54(suppl 63):3844 DISCLOSURES: No relevant relationships by Joseph Glendening, source=Web Response No relevant relationships by Matthew Koroscil, source=Web ResponseCopyright © 2020 American College of Chest Physicians