A woman with abdominal pain while being treated with steroid

Abstract

Introduction/Background Saccharomyces cerevisiae is a yeast of the phylum Ascomycota which can be used in food production. It has rarely been mentioned in the literature as a cause of human disease. Various types of infections have been reported, primarily bloodstream infections. Whether Saccharomyces is a cause of true infection in other sites as compared to a culture contaminant is controversial, as it is considered a normal part of the gastrointestinal (GI), vaginal, and respiratory mucosal flora. The main risk factors for infection with Saccharomyces are immunodeficiency including chemotherapy, history of a central venous catheter, gastroenterological surgery, and use of antibiotics or probiotics. We present the case of an 80-year-old woman who, after five days of dexamethasone treatment for COVID-19 pneumonia, presented with worsening abdominal pain. The patient was diagnosed with perforated diverticulitis, complicated by Saccharomyces cerevisiae fungemia. We will discuss the management of Saccharomyces cerevisiae fungemia and other infections to highlight the difficulty in management and high mortality risk associated with similar infections. Case Presentation An 80-year-old woman with no known medical history was admitted for COVID-19 pneumonia and hypoxia, for which she required four liters of oxygen. She was initially treated with dexamethasone, remdesivir, cefepime, and azithromycin. On the fifth day of hospitalization, she developed acute generalized abdominal pain. Computed tomography of the abdomen and pelvis (figure 2) showed pneumoperitoneum, sigmoid versus terminal ileum perforation, and two abscesses (measuring 5.5 cm and 8 cm in the largest diameters) in the pelvis. Surgical team recommended non-operative management. On days eight and ten of illness, blood cultures were obtained and grew Saccharomyces cerevisiae. Piperacillin-tazobactam was started for empiric GI coverage. Micafungin was started when yeast was identified in blood cultures and was subsequently switched to oral voriconazole once the yeast was identified as Saccharomyces. Blood cultures cleared four days after first positive. Due to persistently worsening leukocytosis, an exploratory laparotomy with sigmoidectomy and end colostomy was performed on day twelve of hospitalization. Intraoperative diagnosis of Hinchey stage IV diverticulitis (diverticulitis with generalized fecal peritonitis) was made. A drain was placed, and cultures from the abscess fluid grew Saccharomyces cerevisiae. In addition to the Saccharomyces isolate, a Mucor species grew in the abscess culture after four days, and the patient was transitioned to liposomal amphotericin B. Two days after amphotericin was started, the patient developed acute encephalopathy to the point where she was non-responsive to pain, believed to be secondary to amphotericin B neurotoxicity. She required transfer to a surgical intensive care unit. Liposomal amphotericin B was changed to intravenous posaconazole. Within 48 hours of stopping amphotericin, the patient s mental status showed moderate improvement and she was disoriented but conversive. She then developed refractory hypoxia and progressive kidney dysfunction, and ultimately required intubation and continuous renal replacement therapy. Surgical team questioned posaconazole as a cause for her worsening renal function, and she was subsequently switched to intravenous Isavuconazole. The patient continued to decline, requiring vasopressor support. She developed refractory metabolic acidosis and lactic acidosis, and hypoxia uncorrected with maximum ventilatory support. The patient s family requested to transition to comfort measures, and the patient expired on day 21 after initial COVID-19 admission. Discussion In one study, Saccharomyces cerevisiae was considered one of the nosocomially acquired infections. It has been reported to cause an average of 1.7% of all fungal cases. Our patient developed Saccharomyces cerevisiae after evidence of diverticulitis complicated by bowel perforation in the setting of being treated with broad-spectr m antibiotics and while not being known to use probiotics. Various types of GI infections have been reported in Saccharomyces cerevisiae, including esophagitis, peritonitis, liver abscess and a link to Crohn s disease, where antibodies to Saccharomyces cerevisiae are a sensitive and specific test. A key element in the management of Saccharomyces cerevisiae is the removal of the infected foreign bodies and the purification of the source. There are no guidelines for dealing with Saccharomyces cerevisiae infections, it is well known that it is susceptible to amphotericin B. Several different types of azole drugs have been investigated, resistance to itraconazole and fluconazole have been reported. Better susceptibility Results were observed with voriconazole and posaconazole. The mortality rate of Saccharomyces cerevisiae fungemia remains high and was reported in one study as 29.5%. Saccharomyces cerevisiae fungemia is a rare, lifethreatening disease with no clearly defined treatment guidelines. Further studies are needed to better understand the therapeutic antifungals options. (Table Presented).