A previously healthy 29-year-old Filipino male presented with pleuritic chest pain, exertional dyspnea, fever, chills, and a 9-kg weight loss over the past 3 months. His medical history was only remarkable for mild COVID-19 with a few days of febrile illness and loss of sense of taste and smell in March 2020. He was not hospitalized and did not undergo any imaging at that time. He was a resident in the Chicago metropolitan area, lived with a male partner, and had a dog. He described his apartment as very humid, where he had several plants, some of which were growing mushrooms in the plant pots. He worked as a designer from home, although disclosed traveling to California, Indiana, and Wisconsin in the past 3 weeks before presentation, but denied any outdoor activities. He had no relevant family or surgical history, denied known allergies to foods or medications, and had no history of sexually transmitted diseases.
His vital signs were notable for fever up to 38.6 °C, heart rate of 101 beats/minute, respiratory rate of 20 breaths/minute, blood pressure of 120/60 mmHg, and saturation of 98% on ambient air. He was in distress secondary to intense chest pain, and the physical exam was only remarkable for a rash in the right cubital fossa. Initial laboratory testing showed leukocytosis (14.1 × 109/L, reference 4.0–11 × 109/L), with neutrophilia (11.3 × 109/L, reference 1–7 × 109/L) and monocytosis (1.2 × 109/L, reference 0.3–1.0 × 109/L), and abnormal C-reactive protein levels (14.5 mg/dL, reference < 1.0 mg/dL). Chest x-ray demonstrated a lobular irregularly shaped soft-tissue density at the left base laterally (Figure 1). Computed tomography (CT) with contrast of the chest showed a left lower lobe 3-cm cavitating mass and peripheral ground-glass opacities within the lung bases bilaterally (Figure 2). The patient was admitted to the general medical floor, and empirical therapy with broad-spectrum antibiotics—intravenous vancomycin and piperacillin–tazobactam—was started. Multiple tests were sent to assess the etiology of the cavitary lesion, including a rapid human immunodeficiency virus (HIV) 1/2 test, Blastomyces dermatitidis and Histoplasma capsulatum urine antigens, Coccidioides immitis antibodies, Cryptococcus neoformans serum antigen, Aspergillus antibodies, interferon-gamma release assay for latent tuberculosis, SARS-CoV-2 Reverse-transcription polymerase chain reaction (RT-PCR), PCR for the detection of methicillin-resistant Staphylococcus aureus, and blood cultures, all of which were reported negative.
Chest radiography showing a lobular irregularly shaped soft-tissue density at the left base laterally (red arrow)
Chest CT showing a left lower lobe cavitating mass measuring up to 3 cm (red arrows) and peripheral ground-glass opacities within the lung bases bilaterally (right: axial plane; left: sagittal plane)
On hospital day 3, a newly developed left-sided pleural effusion was observed on chest x-rays. Antifungal therapy with itraconazole was added, and diagnostic thoracentesis was performed with successful drainage of 140 mL of pleural fluid. The fluid analysis showed an exudative effusion pattern with a pH of 8.5, 498 × 109/L white blood cells, glucose of 61 mg/dL, fluid protein of 3.8 g/dL (serum protein 6.3 g/L, pleural-fluid-to-serum ratio 0.6), and lactate dehydrogenase (LDH) of 1332 U/L (serum LDH 192 U/L, pleural-fluid-to-serum ratio 6.9), but subsequent acid-fast smear, blood, and fungal cultures came back negative. The patient started to improve, and antibiotic treatment was deescalated to cefdinir with the addition of itraconazole given epidemiological risk factors for dimorphic fungal infections (Midwest resident and recent travel to California). He was ultimately discharged on oral therapy (fluconazole, trimethoprim–sulfamethoxazole, and cefdinir) after 5 days with significant clinical improvement.
One week after discharge, the patient returned with constitutional symptoms, pleuritic pain, and cough productive of foul-smelling greenish-yellow sputum that tasted like sulfur. Chest CT showed a new left basilar empyema with air and fluid present within this collection and consolidation in the lingula surrounding the empyema. During this hospitalization, he was tested for antinuclear antibodies (ANA) and anti-neutrophil cytoplasmic antibodies (P-ANCA and C-ANCA) to rule out an autoimmune disease with negative results. The antimicrobial regimen at that point included intravenous meropenem, vancomycin, and voriconazole.
He finally underwent bronchoscopy and left video-assisted thoracoscopic surgery (VATS) decortication with chest tube placement postoperatively and was started on antibiotics with anaerobic coverage. Surgical pathology revealed necrosis with dense acute inflammation and granulation tissue but no microorganisms. Throughout the hospitalization, breathing and cough improved, he remained afebrile, and leukocytosis resolved. The chest tubes were removed after 3 days, and he was subsequently discharged on oral amoxicillin–clavulanate 875–125 mg every 12 hours for 30 days. Despite all the negative cultures, which was expected given the protracted course of antimicrobial therapy, it was concluded that the patient most likely experienced necrotizing bacterial lung infection. Since cavitary lung disease is uncommon in an otherwise healthy young adult, and we ruled out all other conditions from the list of differential diagnoses, it was deduced that a sequela complication of COVID-19 was most likely.
One month after discharge, the patient reported his condition to be progressively improving, but he still reported mild pleuritic pain with deep inspirations and stated that his exercise capacity decreased drastically. Chest x-rays showed improvement in lung lesions.
J Med Case Reports. 2021;15(377) © 2021 BioMed Central, Ltd.