This was a 71-year-old male with a past medical history of benign prostatic hyperplasia (BPH), essential hypertension, and hyperlipidemia who was admitted to Piedmont Columbus Regional Midtown (PCRM) in Columbus, Georgia, United States, with a chief complaint of shortness of breath that started a week ago and has been worsening in the last 24 hours. The patient's weight was 80.3 kg, and his body mass index (BMI) was 30.38 kg/m2. His vital signs on admission were the following: temperature (oral), 36.7oC [98oF]; blood pressure, 157/80 mmHg; heart rate, 75 beats per minute; and respiratory rate, 22 breaths per minute. He had no history of tobacco, alcohol, or illicit drug use. A nasopharyngeal swab was obtained to test for SARS COV-2 using a reverse transcriptase polymerase chain reaction (RT-PCR) test (ID NOW™ COVID-19, Abbott Diagnostics Scarborough, Inc., Scarborough, Maine, United States), and the patient was found to be positive for COVID-19. His SARS-CoV-2 immunoglobulin G (IgG) antibody was found to be negative. He required five liters of oxygen (O2) through a nasal cannula (NC) on admission. The white blood cell (WBC) count on admission was 7.45 x 103/µL [normal range, 4–10.5 103/µL]. Chest X-ray showed bilateral infiltrates and small pleural effusion in the right lung. Infectious diseases service was consulted, and the patient was started on intravenous (IV) remdesivir (VEKLURY®, Gilead Sciences, Inc., Foster City, California, United States) [200 mg IV on day 1, followed by 100 mg IV every 24 hours for five days], dexamethasone [6 mg every 24 hours for ten days], and received a 250 mL of COVID-19 convalescent plasma under the Emergency Use Authorization (EUA) by the United States Food and Drug Administration (FDA). The oxygen requirement increased to 15 L/min through a Venturi mask with a 50% fraction of inspired oxygen (FiO2) and maintaining an O2 saturation at 93%. With the oxygen saturation not improving, the patient changed to a high-flow nasal cannula (HFNC) with an oxygen flow rate of 40 L/min and 95% FiO2. The patient continued to be lethargic and weak, and had elevated inflammatory markers including lactate dehydrogenase (LDH) of 801 U/L [normal range, 120–230 U/L], ferritin of 616 ng/mL [normal range, 40–300 ng/mL], C-reactive protein (CRP) of 7.30 mg/dL [normal range, ≤ 1 mg/dL], fibrinogen of 541 mg/dL [normal range, 200–430 mg/dL], and D-dimer of 18.42 mcg/mL fibrinogen equivalent units (FEU) [normal range, 0.27–0.49 mcg/dL FEU]. The arterial blood gas (ABG) panel showed metabolic acidosis with respiratory compensation, and the patient appeared to be overcompensating due to hypoxia. Consequently, the patient was transferred to the intensive care unit (ICU) for intubation and mechanical ventilation.
On day 7 of admission, the (1->3)-beta-D-glucan assay (Fungitell®, Associates of Cape Cod, Inc., East Falmouth, Massachusetts, United States) and Aspergillus Galactomannan Enzyme Immunoassay (EIA) (Platelia™, Bio-Rad Laboratories, Redmond, Washington, United States) were obtained and resulted negative. Seven days later, a repeat (1->3)-beta-D-glucan was > 500 pg/mL, but the Aspergillus Galactomannan continued to be undetectable. Because the aspartate transaminase (AST) and alanine aminotransferase (ALT) were 243 and 395 U/L, voriconazole could not be initiated, and the patient was started on amphotericin B lipid complex (ABELCET®, Exelead, Inc., Indianapolis, Indiana) [300 mg IV every 24 hours] for possible COVID-associated pulmonary aspergillosis (CAPA). The endotracheal sputum culture obtained on day 13 of admission grew Candida albicans.
On day 10 of admission, the patient was started on cefepime [2 g IV every 12 hours, the dose was renally adjusted for serum creatinine (SCr) of 2.13 mg/dL] and linezolid [600 mg IV every 12 hours] for suspected hospital-acquired pneumonia (HAP). The following day, the liver function panel showed elevated aspartate transaminase (AST) and alanine aminotransferase (ALT) values of 856 and 910 U/L, respectively, and linezolid was discontinued. A subsequent comprehensive metabolic panel (CMP) two days later showed the following: ALT of 7,761 U/L [normal range, 6–52 U/L], AST of 15,185 U/L [normal range, ≤ 42 U/L], total bilirubin of 1.3 mg/dL [normal range, ≤ 1.2 mg/dL], and alkaline phosphatase of 239 U/L [normal range, 35–125 U/L]. The total bilirubin continued to increase over the following days and reached 8 mg/dL, which raised the suspicion of cholecystitis. The abdomen ultrasound showed a gallbladder wall that measures 0.3 cm, no pericholecystic fluid collection, and a sludge within the gallbladder. Acalculous cholecystitis was suspected, and since the patient was a nonoperative candidate, interventional radiology (IR) was consulted for a percutaneous cholecystostomy tube placement. Twenty milliliters of thick bile were aspirated and sent to the microbiology lab for Gram stain and culture. The culture grew Candida albicans. Consequently, amphotericin B was changed to micafungin (MYCAMINE®, Astellas Pharma US, Inc., Northbrook, Illinois, United States) [100 mg IV every 24 hours].
Unfortunately, the patient had a significant deterioration in clinical status and developed septic shock requiring multiple vasopressors. Eventually, the patient's family opted for comfort care measures only.