• PDF / 172,856 Bytes
• 1 Pages / 595.245 x 841.846 pts (A4) Page_size
• 56 Downloads / 195 Views

DOWNLOAD

REPORT

---

1 S

Amphotericin-b/dexamethasone/tocilizumab Bronchopleural fistula, Rhizopus-associated mucormycosis and lack of efficacy: case report

A 49-year-old man developed bronchopleural fistula and Rhizopus-associated mucormycosis during immunosuppressive therapy with tocilizumab and dexamethasone. Additionally, he exhibited lack of efficiacy during treatment with amphotericin-B for Rhizopus-associated mucormycosis [routes, dosages and durations of treatments to reactions onset not stated]. The man presented to emergency department for worsening fever, shortness of breath and cough over 1 week. He was admitted for acute hypoxic respiratory failure secondary to suspected COVID-19 infection. After investigation, he was diagnosed with COVID-19. He started receiving off label empiric antibacterial treatment with ceftriaxone and azithromycin. He also received off label therapy with enoxaparin-sodium [enoxaparin] and dexamethasone along with remdesivir. On the following day, his inflammatory markers increased. Thus, he started receiving tocilizumab to suppresses the interleukin-6 receptor. Eventually, his condition started improving until 2 weeks into his course where he became acutely dyspneic following attempting to exercise. He received advancement to a nonrebreather mask on 10-15 L/min of oxygen. Chest X-ray showed a large right pneumothorax with mediastinal shift. Subsequently, he underwent CT-guided chest tube placement. A repeat chest X-ray demonstrated persistent right pneumothorax. Then, he underwent a second 22-French chest tube placement. Subsequently, only mildly improved right pneumothorax was noted on a chest X-ray. He was transferred to the ICU due to worsening respiratory status. Later, his antibiotic therapy was broadened and immunosuppressive therapy was continued with dexamethasone. The chest tube was advanced to a 36-French size with a general surgery. A CT chest showed a large air-filled bullous process in the posterior right upper lobe, and it suggested bronchopulmonary fistula. Thus, he was intubated for impending respiratory failure. Cardiothoracic surgery was consulted who recommended a right middle invasive thoracotomy for a right bronchopleural fistula repair with pleurodesis. He was found to have a large bronchopleural fistula of the right upper lobe with associated necrotic empyema intraoperatively. Subsequently, the affected area was resected. Initial cultures suggested mucormycosis. Thus, he started receiving amphotericin B. His condition further progressed to bradycardia and subsequent asystole. After 21 days of hospital admission, 7 days of mechanical ventilation, and 5 days after operation, he succumbed to worsening respiratory failure and septic shock despite maximum unspecified vasopressor and antimicrobial therapy. The microbiological analysis of the intraoperative specimens showed positive results for Rhizopus species. Placik DA, et al. Bronchopleural fistula development in the setting of novel therapies for acute respiratory distress syndrome in SARS-CoV-2 pneumonia. Radiology Case 80350