AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Romina Georgina Bórtoli, Physician, Intensive Care Department. Hospital Nacional El Salvador.San Salvador-El Salvador.
Citation: Bórtoli RG, Goméz BCA, Ayala CEA, Cuellar AJD, Camputaro LA, et al. (2021) Pulmonary Candidiasis Associated with Severe COVID-19: Case Report. International Journal of Clinical Case Reports and Reviews. 9(1); DOI:10.31579/2690-4861/166
Copyright: © 2021 Romina Georgina Bórtoli, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 21 August 2021 | Accepted: 09 October 2021 | Published: 14 October 2021
Keywords: COVID-19 – Invasive Candidiasis; Fungal Infections; Pneumonia; Co-infections
Co-infections have been widely described in COVID-19 patients. Bacterial infections being the main cause but also have been reported fungal infections in up to 20 % of the cases. Candida species are the second most common fungi identified in pulmonary mycotic infections affecting hospitalized COVID-19 patients after Aspergillus. We present a case of severe COVID-19 associated with pulmonary candidiasis.
Co-infections have been widely described in COVID-19 patients. Bacterial infections being the main cause but also have been reported fungal infections in up to 20 % of the cases [1-2]. Candida species are the second most common fungi identified in pulmonary mycotic infections affecting hospitalized COVID-19 patients after Aspergillus [3]. We present a case of severe COVID-19 associated with pulmonary candidiasis.
Since the beginning of the COVID-19 pandemic co-infections have been frequently reported, mostly in hospitalized patients with moderate disease (2 - 27%), but also in patients with severe or critical COVID-19 (14 -58%), even more in the deceased (50%) [4]. Health-care associated infections are the cause of an increase in morbidity and mortality in patients with or without coronavirus infection.
The new coronavirus has caused an overload of the healthcare systems worldwide, initially all the effort was conducted to this new disease management. We adapted to this new situation by thoroughly research of the infection mechanisms and its complications, including bacterial and fungal co-infections.
Despite of advances in public health and hospital care, infections still emerge in hospitalized COVID-19 patients. Several microorganisms have been identified as co-pathogens, the bacteria are the most frequent isolated, and in less proportion fungal species. To date, the impact of the latter has not been entirely studied.
Patients with COVID-19 in the intensive care unit (ICU) are at high risk of developing healthcare-associated infections due to the requirement for invasive procedures. In these patients the main risk factors for developing invasive candidemia are: prolonged hospital stay, central venous catheters, surgical procedures and the use of broad-spectrum antibiotics [5].
A 65-year-old female with previous diagnosis of diabetes mellitus, arterial hypertension and chronic kidney disease presented to a peripheral hospital in San Salvador with a 15-day history of fever, headache, dry cough, and progressive dyspnea. Upon admission SARS COV 2 pneumonia was diagnosed. Treatment was initiated according to the national protocol for moderate COVID-19, which at the time included: zinc, ascorbic acid, vitamin D, dexamethasone and anticoagulation with enoxaparin. Imipenem was also started due to a suspected co-infection. A positive urine culture for E. coli (sensitive to carbapenems, amikacin, ceftriaxone and levofloxacin) was reported, so a 4-days antibiotic treatment was completed.
Four days after hospitalization she was referred to our institution and admitted to the ICU due to severe respiratory failure. The patient required oxygen support with a high-flow nasal cannula to achieved an improvement in oxygen saturation and respiratory mechanics.
Laboratory exams on admission presented anemia, leukocytosis with neutrophilia, renal failure, elevated D-dimer and positive non-quantitative troponin (see Table 2). Chest X-ray showed diffuse interstitial-alveolar infiltrates, mainly localized in right lung apex and inferior lobe, without presence of consolidations or evidence of pleural effusion. (Figure 1)
Treatment according to the national protocol for COVID-19 was continued in our institution. Antibiotic therapy with levofloxacin was started for persistent suspicion of sepsis secondary to bacterial co-infection; antiviral treatment with remdesivir was also added.
The third day of hospitalization in our institution the patient had a 7 minutes cardiopulmonary arrest (CA). Non-ST segment elevation acute coronary syndrome was determined as probable CA cause by reason of the multiple cardiovascular risk factors. Post-CA studies showed acute ischemic changes in ECG with positive troponins, for which medical treatment was initiated. In the post-CA care, the patient required invasive mechanical ventilation and sedation analgesia; no need of vasopressors support as the patient present hemodynamic stability. In laboratory exams presented an increased in leucocytes account, suspecting a new nosocomial septic event could be another determinant of the clinical deterioration therefore antibiotic therapy was switch to piperacillin / tazobactam.
The following days, the patient present persistent increase in leukocytosis and required vasopressors as an evidence of organ dysfunction progression despite the use of broad-spectrum antibiotics. Given these clinical findings, an infection resistant to the antibiotics used so far was suspected and treatment with imipenem and vancomycin was started.
Despite broad-spectrum antibiotic treatment, covering possible gram-negative and positive bacteria, radiological deterioration was evidenced as a right apex consolidation, and increase in inflammatory markers in laboratory exams (Figure 2). After receiving a positive result in bronchial aspirate culture for Candida sp, the Infectious Disease Department suspended the antibiotic therapy and started treatment with fluconazole.
Forty eight hours after starting fluconazole, a clinical improvement was evidenced, presented decrease of inflammatory markers and a significant reduction of norepinephrine dose. Furthermore, radiological and oxygenation recovery allowed to reduced mechanical ventilation support. (Figure 3).
As result of the patient clinical condition improvement, progressive sedation de-scalation was performed until suspension, maintaining fentanyl at an analgesic dose. After sedation weaning it was possible to perform a complete neurological examination and a poor neurological response was evidenced (FOUR scale: 5) without sings of focal alterations. In consequence, the mechanical ventilation weaning turned out to be difficult. Unfortunately, the patient died a week after due to complications of post cardiac arrest syndrome.
Invasive Candidiasis in COVID-19
Microorganism of the Candida genus are part of the resident microbiota of the genitourinary and gastrointestinal tracts. However, when an imbalance in the ecological niche occurs, they can cause infections. Candidiasis is the most common invasive fungal infection associated with medical care, with recent global estimates reporting 750,000 cases of invasive candidiasis (IC) per year and more than 50,000 deaths. [6]
Clinical expression of Candida species infection varies from localized symptoms of the mucous membranes to generalized spread with multisystemic organ failure. [7]. Invasive candidiasis is a rare disease but is associated with a 30-day mortality rate over 35% in critically ill patients.
Primary Candida pneumonia is an extremely rare disease, described in less than 1% of cases [8]. Its pathophysiology is not well known, but it is likely associated with hematogenous spread rather than direct contamination due to aspiration. In a monocentric study of patients with mechanical ventilation, only 8% of the tracheal aspirate samples were positive for Candida, considering that 92% was colonization thus the colony count did not exceed the diagnosis threshold for mechanical ventilation associated pneumonia [9].
The incidence of candidemia is related to age, with the highest rates observed at the two ends of life. Various risk factors for the development of candidemia have been identified, allowing for the development of scores to determine the possibility of presenting a candida infection. (Table 3) [6].
The regulation of the host's immune response to the virus is one of the main pillars of COVID-19 treatment, as well as one of the potential risk factors for candida infection in these patients. Some of these treatments include immunosuppressive drugs as glucocorticoids, which have shown to decrease mortality, and also drugs that inhibit IL-6 action. Furthermore, critically ill patients require: prolonged hospitalization, central venous catheters and broad-spectrum antibiotic therapy, which at the beginning of the pandemic was excessive many of the protocols initially included antibiotic coverage at admission], all of these are risk factors for developing invasive infections caused by diverse Candida species [5].
The reported incidence of invasive candidiasis [IC] in COVID ranges from 0.7 to 23%. The pathophysiological mechanisms of COVID-19 are not fully understood, making it difficult to establish the pathogenesis of associated candida infections. The immunocompromise state caused by the coronavirus does not appear to be related to the immunity pathways intervening in candida infections, an example is the lymphopenia found in severe COVID patients, which is not associated to invasive candidiasis. Therefore, the incidence of candida infections is related to the usual risk factors and not to a specific immunocompromise state [5].
Primary Candida pneumonia is considered a rare disease at present, being little information regarding its pathophysiology available, hence the importance of reporting this clinical case. Colonization of the airway by Candida increases with the duration of mechanical ventilation, being 20% in the first 48 hours. Up to 90% of COVID patients who require hospitalization receive antibiotic therapy, which can increase the rate of colonization. Damage to the lung epithelium by viral invasion and the inflammatory response could facilitate the passage of candida into the bloodstream. Another possibility is Candida translocation from the gastrointestinal tract in patients who develop sepsis or septic shock [10].
The diagnosis of invasive Candida infections is challenging, specific characteristics of this type of infection such as transient fungemia, low fungal load in cultured tissues, not using specific culture media for fungi routinely or the need of invasive procedures for taking samples, makes it difficult to achieved microbiological isolation.
A positive blood culture is considered the Gold Standard for the diagnosis of candidemia. [11], but is a low sensitivity method, which varies from 21 to 71
Candida pneumonia is a rare complication in hospitalized patients. The importance of this pathology and others invasive candidiasis in outcomes y mortality in COVID-19 patients is matter of further study.
The authors declare that they have no conflicts of interest.
The publication of the case report was approved by the Committee of Ethics in Investigation Hospital Nacional El Salvador.
Funding
This case report did not have financial support.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
