Abstract Introduction COVID-19 continues to drive ICU admissions and deaths, especially when secondary infections complicate the course. The risk of secondary infections is further amplified by comorbidities such as diabetes. While COVID-19-associated aspergillosis and candidemia are recognized, concurrent infection with multiple pathogens is rarely documented and can lead to poor prognosis. Case Description We present a case of a 59-year-old female type 2 diabetes patient presenting with acute abdomen, hypotension(81/53 mmHg), and leukocytosis (WBC 14,600/ µL). Abdominal X-ray showed free air under the diaphragm. She was diagnosed with peritonitis and subsequently underwent an emergency laparotomy, which revealed a 1.5cm perforated gastric ulcer near the antrum and necrosis of the gallbladder. A Graham patch repair of the ulcer and cholecystectomy was performed. She was transferred to the ICU for septic shock management, and empirical Linezolid and Cefepime were initiated. On day 2, Klebsiella pneumoniae was isolated from wound culture taken intraoperatively, and hence, Linezolid was replaced by Metronidazole. Over the next three days, she showed signs of clinical improvement with steadily decreasing WBC count; however, on day 6, her WBC count considerably increased to 22,000/µl, prompting the inclusion of Micafungin to the antimicrobial regimen. On day 7, she tested positive for SARS-CoV-2 on a nasopharyngeal swab. Over the next 6 days, the patient’s condition continued to deteriorate, and her WBC count peaked at 34,000/µl. On day 13, she developed asystole and died despite efforts to resuscitate. Post-mortem lung biopsy revealed the presence of Aspergillus, Zygomycetes, and Dematiaceous fungi. Discussion Among the first, our case reports a triad of Aspergillus, Zygomycetes, and Dematiaceous fungi in a patient with COVID-19 and diabetes. Although fungal co-infections are recognized in critically ill and immunocompromised hosts, the simultaneous occurrence of three diverse fungal pathogens is rare. The convergence of diabetes, postoperative injury, broad-spectrum antibiotics, vasopressors, and COVID-19-related immune dysregulation likely enabled mixed invasive fungal co-infections. Given that earlier COVID-19 waves were dominated by candidemia and later waves by mucormycosis, proactive fungal screening is crucial in deteriorating ICU patients, when even a broad-spectrum antimicrobial drug regimen does not settle clinical worsening. The scarcity of scientific literature on these co-infections in COVID-19 cases reflects a gap, emphasizing for spreading awareness and further research of invasive fungal co-infections in such a cohort of patients. This abstract is funded by: None
Khan et al. (Fri,) studied this question.