Use of threshold PEP with an adult non-rebreather oxygen mask plus prone positioning in acute hypoxemic respiratory failure due to SARS-CoV-2 infection during the collapse of the health system in a low-income country.

During the coronavirus disease 2019 pandemic, Ecuador reported a collapse of the healthcare system, in which intensive care unit beds were lacking. Therefore, we sought to determine whether the use of threshold expiratory positive pressure with an adult non-rebreather oxygen mask plus prone positioning is useful for improving oxygenation. Twelve patients were included. Eight patients (66.7%) survived, while four patients (33.3%) died. Baseline arterial oxygen saturation (%) prior placement median (interquartile range) 85.5% (80%-89%) and arterial oxygen saturation (%) post placement of the device was median (interquartile range) (93%-96%) (P = 0.0001). Respiratory rate before placement was median (interquartile range) 38 (36-42) and post placement of the device was median (interquartile range) 24 (22-30) (P = 0.0005). The use of an adapted device might be useful for the management of acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 pneumonia, particularly when mechanical ventilators and high-flow oxygen systems are unavailable.

An Unusual Case of Severe Pneumonia Caused Due Candida Tropicalis With a Favorable Clinical Response to Antifungals in a Nonimmunocompromised Patient From the Community.

Severe pneumonia due to Candida tropicalis infection mainly occurs in immunosuppressed patients or those currently receiving broad-spectrum antibiotics. Herein, we report a case of severe pneumonia caused due to C tropicalis in an elderly patient. A 72-year-old man with a previous history of hypertension, ischemic stroke, and facial paralysis sequelae treated with the botulinic toxin, was admitted to the hospital for dyspnea. Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection was negative. Computed tomography of the chest revealed bilateral consolidation with left predominance. A bronchoalveolar lavage sample was sent to molecular biology, but no microorganisms were detected using a FilmArray respiratory panel. However, mamanocandidas test for candida was 166 pg/mL (positive), and fungal structures were identified by the MALDI-TOF Biotyper mass spectrometry and attributed to C tropicalis. Antifungal therapy was started using caspofungin 75 mg as the initial dose followed by 50 mg daily. After 10 days of treatment, ventilatory weaning was achieved. By day 14, the patient was decannulated from the tracheostomy. Oral antifungal treatment with voriconazole was continued, and he was discharged from intensive care in good clinical condition. Severe pneumonia due to C tropicalis might occur in specific cases, especially in those patients with risk factors, and must thus be considered when approaching such cases.

A 71-Year-Old Man From Ecuador With a History of Type 2 Diabetes Mellitus and Severe COVID-19 Pneumonia and Lung Cavitation Associated With Triple Infection With Trichosporon Asahii, Klebsiella Pneumoniae, and Pseudomonas Aeruginosa.

Unvaccinated patients with comorbidities that impair the immune function, such as type 2 diabetes mellitus, are more likely to develop severe COVID-19. The COVID-19-associated acute respiratory distress syndrome has raised new concerns in intensive care units globally owing to the presence of secondary fungal infections. We report the case of a 71-year-old man from Ecuador with a history of type 2 diabetes mellitus, severe COVID-19 pneumonia, and lung cavitation associated with triple infections with Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient with a history of high blood pressure and type 2 diabetes was admitted to our hospital from a private care center with a diagnosis of COVID-19-associated acute respiratory distress syndrome. On arrival, the patient presented with signs of hypoxemic respiratory failure. During his stay at another hospital, he had received tocilizumab and corticosteroid therapy. Therefore, intubation was performed and mechanical ventilation was initiated. The patient developed a septic shock and renal failure with a glomerular filtration rate of 27.5 mL/min/1.73 m2; therefore, two hemodiafiltration sessions were started. The bronchoalveolar lavage revealed erythematous lesions in the bronchial tree and abundant purulent secretions and erosions in the bronchial mucosa, with a cavitary lesion in the right bronchial tree. The bronchoalveolar lavage samples were used to isolate Trichosporon asahii, Klebsiella pneumoniae, and Pseudomonas aeruginosa carbapenemase class A. Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) Biotyper mass spectrometry and polymerase chain reaction (PCR) molecular identification were performed. This case report suggested that patients with severe COVID-19 pneumonia, with or without comorbidities, are more susceptible to opportunistic infections.

Management of COVID-19 at the pandemic's first wave in Ecuador.

During March and April 2020, Ecuador was the country with the highest death toll in Latin America due to the coronavirus disease 2019 pandemic. Simultaneously, research was being developed and published globally, and to a certain extent, guided therapeutic approaches in real time, mostly in under-resourced settings. We present the case of a 59-year-old male physician residing in Guayaquil, who presented with severe coronavirus disease 2019, in which mechanical ventilation, prone position, and pulmonary protective ventilatory strategy were used. We discuss the clinical management of the first reported case in the literature of a physician in Ecuador who survived severe acute respiratory syndrome coronavirus 2 infection, as well as the topic of self-medication within health professionals, the management approach that was emerging at the moment in scientific publications and guiding treatment, the role of responsible research and its worldwide impact, and the emotional burdens of the care team who had to make very difficult decisions in extremely adverse circumstances.

Telemedicine and Home-Based Treatment of COVID-19 in Resource-Limited Countries. Report of 3 Cases.

Ecuador, despite having taken aggressive and early measures to stop the progression of the pandemic (COVID-19), ended up becoming an epicenter of the pandemic in Latin America, and with the collapse of its health care system. The authors describe three patients who had confirmed COVID-19 and met the criteria for hospital admission but could not be assigned a hospital bed in a resource-limited country. The patients included a 72-year-old male, an 82-year-old female, and a 56-year-old male. They typically presented with fever, dyspnea, loss of taste and smell, diarrhea, and abdominal pain. Oxygen saturation during the initial evaluation ranged from 80-89%. Laboratory results reported lymphopenia and neutrophilia, with leukocytosis in two patients. Inflammatory markers were also elevated for all three patients. CT scan findings showed bilateral ground-glass pulmonary opacities. SARS-CoV-2 was confirmed in all three patients by real time polymerase chain reaction (RT-PCR) testing. Home-based treatment was established. At the time of writing this report, all patients remain asymptomatic and with negative COVID-19 testing. Telemedicine and home-based treatment were essential assets in the care of these severely ill patients living in a low-resource setting where not all patients who have criteria to be admitted into the hospital are able to find a place in a collapsed health care system.