Case Images
Necrotizing pneumonia due
to Pseudomonas aeruginosa secondary to severe COVID-19 pneumonia
Jun Hirai1,2,
Nobuaki
Mori1,2, Nobuhiro Asai1,2, Hiroshige
Mikamo1,2
1 Department of Clinical Infectious Diseases, Aichi
Medical University Hospital, Aichi, Japan
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:hiraichimed@gmail.com
Keywords: COVID-19, necrotizing pneumonia, 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 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.1 NP occurs
as a complication in 0.8% of cases of community-acquired
pneumonia.2 The most common pathogens areStaphylococcus aureus and Streptococcus
pneumoniae .3 In patients with COVID-19 pneumonia on
invasive mechanical ventilation, the incidence of NP ranges from less
than 0.5%4 to 4.5%, and Klebsiella pneumoniaeand P. aeruginosa are the most common
pathogens.5 A retrospective study reported NP was
diagnosed at a median of 27 days after COVID-19 symptom
onset.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.