PMC8683162_01
Flow chart outlining the timeline of events surrounding T. asahii infection, treatment, and resolution.
CRIID2021-6841393.001.jpg
PMC8683162_01_CRIID2021-6841393.001.jpg
fig1
During the second month of his hospital stay, after his initial antibiotics courses had been completed, due to worsening respiratory status, sputum cultures were performed on hospital day (HD) # 26 which revealed Stenotrophomonas maltophilia and Citrobacter koseri, which were treated with trimethoprim-sulfamethoxazole (Figure 1). Urinalysis, urine cultures, blood cultures, and a chest X-ray were ordered on the same day (Figure 1). Urinalysis revealed 38 red blood cells per High Powered Field (HPF), 13 white blood cells/HPF, 2+ bacteria, many budding yeast, and 3+ hyaline casts (Figure 1). Leukocytosis was only mild (10.6 cells per cubic millimeter of blood), but continued to increase to 15 cells per cubic millimeter of blood over the ensuing four days (Figure 1). On HD # 58, the patient again experienced a febrile episode, with a maximum temperature of 103.0 F accompanied by a leukocyte increase from 10 to 15 cells per cubic millimeter of blood (Figure 1). T. asahii, the febrile episode, and leukocyte increase despite broad-spectrum antibiotics, antifungal coverage was deemed necessary. The patient was started on empiric fluconazole on HD # 58, and his Foley catheter was again replaced that same day (Figure 1). Treatment with trimethoprim-sulfamethoxazole was again started (Figure 1). Based on the advanced fungal testing, voriconazole was started on HD # 65 (following seven days of fluconazole) per infectious disease recommendations and continued for seven days (Figure 1). T. asahii was no longer present in urine (Figure 1).