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Rare multi-fungal sepsis: a case of triple-impact immunoparalysis
Bretislav Lipovy1,2, Martin Hladik1, Katerina Vyklicka3
1Department of Burns and Plastic Surgery, Faculty of Medicine, Institution Shared With University Hospital Brno, Masaryk University, Jihlavska 20, Brno, Czech Republic.
Abstract:
Patients with burn injury and inhalation injury are highly susceptible to infectious complications, including opportunistic pathogens, due to the loss of skin cover and mucosal damage of respiratory tract as well as the disruption of homeostasis. This case report, a 34-year-old man suffered critical burns, provides the first literature description of triple-impact immunoparalysis (critical burns, inhalation injury, and SARS-CoV-2 infection), leading to a lethal multifocal infection caused by several fungi including very rare environmental representatives Metschnikowia pulcherrima and Wickerhamomyces anomalus. The co-infection by these common environmental yeasts in a human is unique and has not yet been described in the literature. Importantly, our patient developed refractory septic shock and died despite targeted antifungal therapy including the most potent current antifungal agent-isavuconazole. It can be assumed that besides immunoparalysis, effectiveness of therapy by isavuconazole was impaired by the large distribution volume in this case. As this is a common situation in intensive care patients, routine monitoring of plasmatic concentration of isavuconazole can be helpful in personalization of the treatment and dose optimization. Whatmore, many fungal species often remain underdiagnosed during infectious complications, which could be prevented by implementation of new methods, such as next-generation sequencing, into clinical practice.
Insights
A critical burn, inhalation injury, and SARS-CoV-2 infection led to a rare fungal co-infection. This triple immunoparalysis resulted in fatal septic shock, highlighting diagnostic and therapeutic challenges in critical care.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Mycology
Background:
- Burn and inhalation injuries compromise immune defenses, increasing susceptibility to opportunistic infections.
- Patients with severe injuries face risks from pathogens due to disrupted homeostasis and damaged barriers.
- The interplay between critical illness, viral infection, and fungal co-infections presents complex clinical challenges.
Observation:
- A 34-year-old male with critical burns and inhalation injury developed SARS-CoV-2 infection.
- This triple-impact immunoparalysis led to a unique, lethal multifocal infection involving rare fungi: Metschnikowia pulcherrima and Wickerhamomyces anomalus.
- The patient experienced refractory septic shock despite treatment with isavuconazole.
Findings:
- This case represents the first documented co-infection of Metschnikowia pulcherrima and Wickerhamomyces anomalus in a human.
- Despite potent antifungal therapy, the patient succumbed to the infection, suggesting potential therapeutic limitations.
- Large distribution volume of isavuconazole in intensive care patients may impair treatment efficacy.
Implications:
- Routine monitoring of isavuconazole plasma concentrations could aid in personalizing treatment and optimizing dosage in critical care.
- Advanced diagnostic methods like next-generation sequencing are crucial for identifying underdiagnosed fungal co-infections.
- Understanding triple-impact immunoparalysis is vital for improving outcomes in critically ill patients with complex infections.
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