Scientific Letter
Trichosporon asahii as Cause of Nosocomial Pneumonia in Patient With COVID-19: A Triple Co-infection
Neumonía nosocomial por Trichosporon asahii en un paciente con covid-19: una coinfección triple
Gonzalo Segrelles-Calvoa,b, Glauber R. De S. Araújoc, Estefanía Llopis-Pastora, Susana Frasésc,
Corresponding author
a Servicio de Neumología, Hospital Universitario Rey Juan Carlos, Madrid, Spain
b Instituto de Investigación Biomédica, Fundación Jiménez Díaz, Madrid, Spain
c Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Araújo, Estefanía Llopis-Pastor, Susana Frasés" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Gonzalo" "apellidos" => "Segrelles-Calvo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "Glauber R. De S." "apellidos" => "Araújo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Estefanía" "apellidos" => "Llopis-Pastor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "Susana" "apellidos" => "Frasés" "email" => array:1 [ 0 => "susanafrases@biof.ufrj.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Rey Juan Carlos, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica, Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Laboratório de Biofísica de Fungos, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía nosocomial por <span class="elsevierStyleItalic">Trichosporon asahii</span> en un paciente con covid-19: una coinfección triple" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2181 "Ancho" => 3417 "Tamanyo" => 816072 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Timeline for an immunocompetent COVID-19 patient who developed an invasive pulmonary trichosporonosis by <span class="elsevierStyleItalic">Trichosporon asahii</span>. The patient was admitted to the intensive care unit on the 12th day after a positive diagnosis by SARS-CoV-2 and died after 24 days. Abbreviations: AZT: Azithromycin HCQ: Hydroxychloroquine sulfate LPN/RTN: Lopinavir/Ritonavir MTP: Methylprednisolone TCZ: Tocilizumab BAS: Bronchial Aspiration CT: Computer Tomography Multi-R: Multi-resistant ICU: Intensive Care Unit CPAP: Continuous Pressure in Upper Airway NIMV: Non-Invasive Mechanical Ventilation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">COVID-19, a viral disease caused by the SARS-CoV-2, is a lethal infection in a significant number of cases with several clinical manifestations and symptoms, such as lung damage, exacerbated inflammatory response and, in many cases, generalized organ failure.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> To combat these symptoms, one or more immunosuppressive drugs can be used individually or in combination<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a>; therefore, the treatment itself can impose an additional risk for the development of fungal infections. It is important to emphasize that there are other associated risk factors, such as malnutrition, prolonged intubation, central and/or arterial venous access, and the need for a nasogastric tube that can increase the chances of mycosis infections in patients suffering from severe cases of COVID-19.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> In the past few decades, the world has experienced an increase in the incidence and spread of emerging fungal infections. This scenario has caused a fundamental change in the epidemiology of invasive fungal diseases, especially in immunocompromised individuals, such as those affected by human immunodeficiency virus (HIV), cancer, or undergoing transplants.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Among these emerging pathogens, fungal infections caused by <span class="elsevierStyleItalic">Trichosporon asahii</span> have been identified in neutropenic cancer patients, which significantly increased the severity of their cases leading to a high mortality rate. Recently, the infection has also been identified in other groups of immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Here, we report a case of an immunocompetent patient suffering from a severe case of COVID-19 infection who also developed a triple pulmonary coinfection with <span class="elsevierStyleItalic">Pseudomonas</span> sp., <span class="elsevierStyleItalic">Stenotrophomonas</span> sp. and <span class="elsevierStyleItalic">Trichosporon</span> sp.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient reported in this study was a 58-year-old male patient that, in 2000, presented a mild chronic kidney disease and had a tuberculosis infection treated with isoniazid chemoprophylaxis. In 2004, he was diagnosed with a bladder neoplasm and was submitted to a radical cystoprostatectomy and a left nephrectomy due to a renal metastasis. The patient had been free of malignant disease for the past ten years and had a competent immune status.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient went to the emergency room (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> – Day 1) after presenting, for twelve days, high fever, unproductive cough, and general affection. Twenty-four hours before going to the hospital, the patient presented dyspnea with moderate efforts (∼90% SpO<span class="elsevierStyleInf">2</span> at rest). A blood test confirmed lymphopenia (900/mm<span class="elsevierStyleSup">3</span>), high C-Reactive Protein (CRP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mg/dL), and altered transaminases (Glutamic Oxaloacetic Transaminase (GOT) 160<span class="elsevierStyleHsp" style=""></span>IU/L; Glutamate Pyruvic Transaminase (GPT) IU/L; Gamma Glutamyl Transpeptidase (GGT) 75<span class="elsevierStyleHsp" style=""></span>IU/L, and Phosphatase Alkaline (PAL) 60<span class="elsevierStyleHsp" style=""></span>IU/L). Chest X-ray images revealed an infiltration in the left base of the lung and the COVID-19 test was positive. With the diagnosis of pneumonia secondary to SARS-CoV-2, the patient was admitted to the Intensive Care Unit (ICU). A treatment off-label with Hydroxychloroquine sulfate 400<span class="elsevierStyleHsp" style=""></span>mg (equivalent to 310<span class="elsevierStyleHsp" style=""></span>mg base) Q12H for 2 doses, followed by 200<span class="elsevierStyleHsp" style=""></span>mg (=155 base) Q12H for 5 days), Lopinavir/Ritonavir (400<span class="elsevierStyleHsp" style=""></span>mg/100<span class="elsevierStyleHsp" style=""></span>mg), Azithromycin (500<span class="elsevierStyleHsp" style=""></span>mg daily for three days), Methylprednisolone (bolus of 125<span class="elsevierStyleHsp" style=""></span>mg daily for three days), and Tocilizumab (two doses of 8<span class="elsevierStyleHsp" style=""></span>mg/kg IV – 8<span class="elsevierStyleHsp" style=""></span>h apart) was prescribed and initiated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">During hospitalization (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the respiratory function of the patient aggravated and a high oxygen flow [50 LPM and 90% Fraction of Inspired Oxygen (FiO<span class="elsevierStyleInf">2</span>)] was needed. Finally, an orotracheal intubation and an invasive ventilation was needed on the 12th day of hospitalization in the ICU. On the 19th day (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), multiresistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Stenotrophomonas maltophila</span> strains were isolated from the respiratory secretions of the patient. Despite the treatment with antibiotics, the clinical course of the infection had a poor outcome, and the patient presented persistent fever and hypoxemic respiratory failure. In a chest radiographic exam, left pneumothorax was detected and a chest drainage was performed. A chest CT scan was performed and a suspected pleuro-pulmonary fistula in the lingular zone, a moderate pleural effusion, and bilateral infiltrates were visualized. Following these results, a fiber bronchoscopy was performed in which abundant purulent secretions, mainly in the right bronchial tree, were visualized and aspirated. Endobronchial lesions were not identified. In the collected respiratory secretions, <span class="elsevierStyleItalic">Trichosporon asahii</span> was isolated and a treatment with antifungal drugs (voriconazole) started in day 28th (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The clinical response was weak and the patient developed a septic shock and died on the 38th day after his transfer to the ICU (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The family of the patient authorized the autopsy. The pulmonary autopsy study confirmed the existence of a pattern of acute alveolar damage.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Every day, a discovery regarding the pathophysiological behavior of SARS-CoV-2 emerges. The SARS-CoV-2 causes a lower respiratory infection which in turn can lead to Acute Respiratory Discomfort Syndromes (ARDS). In addition to a diffuse alveolar damage with severe inflammatory exudation, patients with COVID-19 can present immunosuppression with decreased CD4+T and CD8+ T cells.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> This clinical scenario opens the door for the development of coinfections by opportunistic microorganisms. Within this context, different published reports have shown the importance of assistant doctors and laboratory specialists in verifying the occurrence of potential coinfections, such as aspergillosis, candidiasis, mucormycosis, or cryptococcosis that could lead to co-morbidities in patients with COVID-19.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The incidence of invasive infections caused by opportunistic fungal species has increased in recent decades. These fungi are normally difficult to diagnose, resistant to many antifungals, and are associated with high mortality rates.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> In the 1980s, the invasive <span class="elsevierStyleItalic">Trichosporon</span> infection was considered the second most common cause of fungemia among immunosuppressed patients who also suffered from hematological diseases, hemochromatosis, end-stage renal disease, or who were on a long-term corticosteroid treatment. Depending on the age, underlying conditions, presence of neutropenia, and clinical treatments, the mortality rates of patients suffering from an invasive tricosporonosis infection can range from 30% to 90%.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9–11</span></a> Until now, our case is the first report that shows a <span class="elsevierStyleItalic">Trichosporon</span> infection in a COVID-19 patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we report a case of a triple pulmonary coinfection in an immunocompetent patient with severe SARS-CoV-2 pneumonia. As the pandemic continues to spread around the world, other reports to assess the frequency of emergent and reemerging highly resistant bacterial and fungal coinfections in individuals suffering from COVID-19 are needed. These coinfections impose severe complications in COVID-19 patients that might lead to death due to the aggravation in the primary viral condition.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics declarations</span><p id="par0045" class="elsevierStylePara elsevierViewall">The present study was approved by the Ethics Committee of the Fundación Jiménez Díaz Health Research Institute (EO102-20-HRJC). Due to the pandemic situation, informed consent was not requested from the patients. Personal information and data obtained from the subjects were kept confidential.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethics declarations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:2 [ "identificador" => "xack579918" "titulo" => "Acknowledgements" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2181 "Ancho" => 3417 "Tamanyo" => 816072 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Timeline for an immunocompetent COVID-19 patient who developed an invasive pulmonary trichosporonosis by <span class="elsevierStyleItalic">Trichosporon asahii</span>. The patient was admitted to the intensive care unit on the 12th day after a positive diagnosis by SARS-CoV-2 and died after 24 days. Abbreviations: AZT: Azithromycin HCQ: Hydroxychloroquine sulfate LPN/RTN: Lopinavir/Ritonavir MTP: Methylprednisolone TCZ: Tocilizumab BAS: Bronchial Aspiration CT: Computer Tomography Multi-R: Multi-resistant ICU: Intensive Care Unit CPAP: Continuous Pressure in Upper Airway NIMV: Non-Invasive Mechanical Ventilation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary pathology and COVID-19: lessons from autopsy. The experience of European Pulmonary Pathologists" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Calabrese" 1 => "F. 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This work was supported by the Brazilian agencies Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) – Finance Code 001 and Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/00000057000000S2/v4_202201070724/S0300289620305275/v4_202201070724/en/main.assets" "Apartado" => array:4 [ "identificador" => "49741" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Scientific Letters / Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/00000057000000S2/v4_202201070724/S0300289620305275/v4_202201070724/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620305275?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 5 | 15 |
| 2024 October | 95 | 29 | 124 |
| 2024 September | 110 | 15 | 125 |
| 2024 August | 141 | 53 | 194 |
| 2024 July | 90 | 20 | 110 |
| 2024 June | 117 | 33 | 150 |
| 2024 May | 118 | 28 | 146 |
| 2024 April | 74 | 24 | 98 |
| 2024 March | 67 | 19 | 86 |
| 2024 February | 58 | 42 | 100 |
| 2024 January | 75 | 43 | 118 |
| 2023 December | 58 | 31 | 89 |
| 2023 November | 84 | 39 | 123 |
| 2023 October | 79 | 35 | 114 |
| 2023 September | 70 | 35 | 105 |
| 2023 August | 96 | 31 | 127 |
| 2023 July | 89 | 23 | 112 |
| 2023 June | 64 | 24 | 88 |
| 2023 May | 96 | 23 | 119 |
| 2023 April | 68 | 39 | 107 |
| 2023 March | 110 | 61 | 171 |
| 2023 February | 89 | 32 | 121 |
| 2023 January | 78 | 31 | 109 |
| 2022 December | 98 | 21 | 119 |
| 2022 November | 134 | 35 | 169 |
| 2022 October | 109 | 41 | 150 |
| 2022 September | 92 | 39 | 131 |
| 2022 August | 106 | 51 | 157 |
| 2022 July | 77 | 53 | 130 |
| 2022 June | 74 | 48 | 122 |
| 2022 May | 76 | 38 | 114 |
| 2022 April | 113 | 60 | 173 |
| 2022 March | 107 | 46 | 153 |
| 2022 February | 189 | 30 | 219 |
| 2022 January | 113 | 40 | 153 |
| 2021 December | 86 | 20 | 106 |
| 2021 November | 90 | 29 | 119 |
| 2021 October | 70 | 49 | 119 |
| 2021 September | 57 | 29 | 86 |
| 2021 August | 81 | 35 | 116 |
| 2021 July | 83 | 39 | 122 |
| 2021 June | 109 | 50 | 159 |
| 2021 May | 84 | 51 | 135 |
| 2021 April | 150 | 50 | 200 |
| 2021 March | 85 | 44 | 129 |
| 2021 February | 61 | 22 | 83 |
| 2021 January | 40 | 12 | 52 |
| 2020 December | 2 | 0 | 2 |
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