PREVOTELLA BIVIA BACTEREMIA POST TOCILIZUMAB IN A PATIENT WITH SEVERE COVID-19 PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Anaerobes generally constitute a major component of the gut microbiome. They play a significant role in the pathogenesis of infections following disruption of mucosal integrity. Anaerobic organisms are usually difficult to grow and identify and hence may often be overlooked. We present a patient with severe COVID-19 pneumonia who developed de-novo Prevotella bivia bacteremia, following tocilizumab. CASE PRESENTATION: A 38 year old Caucasian male with morbid obesity and no other past medical history presented to the emergency department with complaints of cough, fever, chills and poor appetite for the past 10 days. Upon arrival, he was profoundly hypoxic with Spo2 70% on ambient air. He tested positive for COVID-19. On physical examination, his BMI was 62 kg/m2, he was febrile, in moderate respiratory distress, cardiopulmonary examination revealed coarse bilateral breath sounds. His physical examination was otherwise unremarkable. His chest radiograph demonstrated hazy opacification in both mid lungs and left lung base suggestive of multifocal pneumonia. CT chest did not reveal evidence of pulmonary embolism. Lower extremity ultrasound was however negative for a DVT. Laboratory findings was significant for elevated C-reactive protein 12.4 mg/dl. Patient was placed on heated high flow nasal cannula and received dexamethasone and tocilizumab. His respiratory status continued to worsen and he was subsequently intubated. Lower respiratory culture was positive for MSSA and patient was started cefepime and vancomycin was added as he clinically continued to decompensate. Within the next week, blood culture was positive for Prevotella bivia and his antibiotic regimen was changed to pipericillin-tazobactam. Repeat blood culture continued to be positive and this time, for Enterococcus faecalis. The antibiotic regimen was further changed to meropenem. Interestingly, on his physical examination, there was no abnormalities on his abdomen or pelvic area. CT abdomen pelvis did not shows any acute abnormalities. Following meropenem initiation, his subsequent blood cultures have been negative for any growth. Patient remains intubated with a guarded prognosis. DISCUSSION: Prevotella bivia is one of several species of bacteria in the genus Prevotella. It is an anaerobic gram negative organism that is found in the oral, vaginal, and gut microbiome. Some of the infections caused by this organism include aspiration pneumonia, lung abscess, otitis media, and sinusitis. Various species of Prevotella have been isolated from abscesses and burns close of the mouth, bite, paronychia, urinary tract infection, brain abscess, osteomyelitis, and bacteremia when there is an associated respiratory tract infections. Prevotella bivia bacteremia is highly uncommon. CONCLUSIONS: As we continue to learn more about COVID-19 infection and its treatment modalities, we may come across such unusual scenarios. REFERENCE #1: 27.Curtis JR, Perez-Gutthann S, Suissa S, et al. Tocilizumab in rheumatoid arthritis: a case study of safety evaluations of a large postmarketing data set from multiple data sources. Semin Arthritis Rheum 2015;44:381. REFERENCE #2: Yanagisawa M, Kuriyama T, Williams DW, Nakagawa K, Karasawa T. Proteinase activity of prevotella species associated with oral purulent infection. Curr Microbiol. 2006;14(5):375–378. doi: 10.1007/s00284-005-0261-1 REFERENCE #3: Metronidazole Resistance in Prevotella spp. and Description of a New nim Gene in Prevotella baroniaeC. Alauzet, F. Mory, C. Teyssier, H. Hallage, J. P. Carlier, G. Grollier, A. Lozniewski DISCLOSURES: No relevant relationships by Alfred Aiyanyor, source=Web Response No relevant relationships by Navitha Ramesh, source=Web Response No relevant relationships by Q. Kamran Uddin, source=Web Response