(641) Elizabethkingia and Severe Pulmonary Coccidioidomycosis: A Novel Case in California’s Central Valley

Introduction: Elizabethkingia anophelis (EA) is a gram-negative aerobic bacterium first identified in the mid-gut of mosquitoes in 2010. Elizabethkingia species are known to cause meningitis, pneumonia, and bacteremia, with initial case reports in the United States emerging from the Midwest. The origin of these infections remains unidentified. We present the first reported case of EA blood infection in California's Central Valley, superimposed on severe pulmonary coccidioidomycosis.

Description: A 24-year-old female initially presented with fever, pleuritic chest pain, and respiratory failure requiring mechanical ventilator a day after admission. Serology, autoimmune and viral workup were unremarkable, and the patient was transferred to our ICU for venous extracorporeal membrane oxygenation support (VV-ECMO). She underwent bronchoscopy with transbronchial biopsy at her initial facility which revealed features suspicious of organizing pneumonia. She received broad-spectrum antibiotics and dexamethasone. Upon transfer, her diffuse pulmonary infiltrates and gas exchange worsened, leading to VV-ECMO cannulation. A repeat bronchoscopy was performed at our hospital, and EA and Coccidioides immitis (CI) grew in the BAL samples. The patient was treated with fluconazole, levofloxacin, and piperacillin-tazobactam. Despite prolonged VV-ECMO support and antimicrobial therapy her blood cultures continue to grow EA and CI. Given a prolonged critical illness course the patient and her family decided to transition her care to comfort measures.

Discussion: We suspect the severe coccidioidomycosis led to an opportunistic EA-superimposed infection. Pulmonary coccidiomycosis, although often a self-limiting infection, can cause structural lung lesions, providing opportunities for superimposed infections. Prior case reports associate EA infection as nosocomial infection and could potentially be traced to contaminated water sources; however, our patients reported poultry farming as a potential exposure of significance. Further investigation of the relationship between EA, poultry farming, and fungal infections could aid in preventing EA infection and outbreaks as EA species are known to carry many multidrug resistance genes with a relatively high mortality rate.