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\begin{document}

\title{Necrotizing pneumonia due to Pseudomonas aeruginosa secondary to severe
COVID-19 pneumonia}



\author[1]{JUN HIRAI}%
\author[1]{NOBUAKI MORI}%
\author[1]{NOBUHIRO ASAI}%
\author[1]{HIROSHIGE MIKAMO}%
\affil[1]{Aichi Medical University Hospital}%


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  \date{May 16, 2024}


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\begin{abstract}
Necrotizing pneumonia (NP) is a severe form of lung disease with a high
mortality rate. Although NP generally occurs as a complication in
community-acquired pneumonia, our case illustrates that NP can occur as
a secondary infection even if the clinical course of COVID-19 pneumonia
is favorable, particularly in intubated patients.%
\end{abstract}%



\sloppy


\emph{Case Images}

\textbf{Necrotizing pneumonia due to \emph{Pseudomonas aeruginosa}
secondary to severe COVID-19 pneumonia}

Jun Hirai\textsuperscript{1,2}, Nobuaki Mori\textsuperscript{1,2},
Nobuhiro Asai\textsuperscript{1,2}, Hiroshige
Mikamo\textsuperscript{1,2}

\textsuperscript{1} Department of Clinical Infectious Diseases, Aichi
Medical University Hospital, Aichi, Japan

\textsuperscript{2} Department of Infection Control and Prevention,
Aichi Medical University Hospital, Aichi, Japan

Address correspondence to: Dr. Jun Hirai, Department of Clinical
Infectious Diseases, Aichi Medical University, 1-1 Yazakokarimata,
Nagakute-shi, Aichi 480-1195, Japan.

Tel: +81-561-62-3311

Fax: +81-561-61-1842

E-mail:\emph{hiraichimed@gmail.com}

\textbf{Keywords:} COVID-19, necrotizing pneumonia, \emph{Pseudomonas
aeruginosa} , mechanical ventilation, secondary infection

A 60-year-old man was admitted to our hospital with a 7-hour history of
dyspnea. On admission, his vital signs were as follows: blood pressure,
90/56 mmHg; heart rate, 112 beats/min; body temperature, 40.5;
respiratory rate, 32 breaths/min; and oxygen saturation, 88\% on 15
L/min oxygen via a reservoir mask. He was diagnosed with severe COVID-19
pneumonia, confirmed by polymerase chain reaction testing, intubated and
admitted to the intensive care unit the diagnosis of severe COVID-19
pneumonia. Computed tomography (CT) of the chest showed bilateral
diffuse ground-glass opacities primarily in the upper lobes and
consolidation in the lower lobes (Figure 1a-c), but no evidence of
pulmonary embolism on contrast-enhanced CT. The patient was treated with
remdesivir (200 mg loading dose on day 1, followed by 100 mg daily for
up to 9 additional days), dexamethasone (6.6 mg/day), and baricitinib (4
mg/day) for 10 days, according to the current recommendations for
COVID-19 management. He gradually recovered and was afebrile with a
stable respiratory condition after completing 10 days of treatment.
However, on hospital day 12, he developed a fever (39.8) and recurrent
respiratory distress. Chest CT revealed new multifocal consolidations
with thick-walled cavitation in both lungs (Figure 1d-f) and he was
diagnosed with necrotizing pneumonia (NP). We immediately started
tazobactam/piperacillin (18 g/day), but the patient died the next day.
Sputum and two sets of blood cultures obtained on hospital day 12
confirmed \emph{Pseudomonas aeruginosa} . However, the tip of the
central venous catheter culture revealed no organism and transthoracic
echocardiography showed no obvious vegetation of the heart valves.

Necrotizing pneumonia is a severe form of lung disease including
necrosis of lung parenchyma with the formation of abscesses and
cavitation and has a high mortality rate.\textsuperscript{1} NP occurs
as a complication in 0.8\% of cases of community-acquired
pneumonia.\textsuperscript{2} The most common pathogens
are\emph{Staphylococcus aureus} and \emph{Streptococcus pneumoniae}
.\textsuperscript{3} In patients with COVID-19 pneumonia on invasive
mechanical ventilation, the incidence of NP ranges from less than
0.5\%\textsuperscript{4} to 4.5\%, and \emph{Klebsiella pneumoniae}and
\emph{P. aeruginosa} are the most common pathogens.\textsuperscript{5} A
retrospective study reported NP was diagnosed at a median of 27 days
after COVID-19 symptom onset.\textsuperscript{5}

This case illustrates that NP can occur as a secondary infection even if
the clinical course of COVID-19 pneumonia is favorable, particularly in
patients on invasive mechanical ventilation.

\textbf{Author contribution}

J.H. contributed to writing and editing of the manuscript. N.M.
contributed to conceptualization. N.A. and H.M. contributed to
supervision and validation.

\textbf{Consent for publication}

Written informed consent was obtained from the patient's family for the
publication of this case report and the accompanying images.

\textbf{Conflict of interest}

All the authors have declared no competing interests.

\textbf{References}

1. Krutikov M, Rahman A, Tiberi S. Necrotizing pneumonia (aetiology,
clinical features and management). \emph{Curr Opin Pulm Med.} 2019
May;25(3):225--32.

2. Akagi Fukushima E, Bhargava A. Unusual case of necrotizing pneumonia
caused by Fusobacterium nucleatum complicating influenza a virus
infection. \emph{Anaerobe} . 2021 Jun;69:102342.

3. Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of
pneumonia requiring special consideration. \emph{Curr Opin Pulm
Med.}2012 May;18(3):246--52.

4. Gurumurthy B, Das SK, Hiremath R, Shetty S, Hiremath A, Gowda T.
Spectrum of atypical pulmonary manifestations of COVID-19 on computed
tomography. \emph{Egypt J Radiol Nuci Med} . 2021 Dec; 52(1):72.

5. Hidron A, Quiceno W, Carde\selectlanguage{ngerman}ño JJ, Roncancio G, García C. Post-COVID-19
Necrotizing Pneumonia in Patients on Invasive Mechanical
Ventilation.\emph{Infect Dis Rep.} 2021 Sep 8;13(3):835--42.

\textbf{Figure legend}

\textbf{Figure 1.} Course of the patient's COVID-19 pneumonia and
necrotizing pneumonia due to \emph{Pseudomonas aeruginosa} . (a-c) Chest
computed tomography findings on admission showing bilateral ground-glass
opacities in the upper lobe, and bilateral consolidation in the lower
lobe of both lungs. (d-f) Chest computed tomography findings on hospital
day 12 showing multiple thick-walled cavities with patchy shadows and
ground-glass opacities detected as new findings, with near-complete
resolution of the bilateral ground-grass opacities and consolidation
detected on admission.\selectlanguage{english}
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