Rapid Succession of Multidrug-Resistant Bacteremia and Candidemia in a Patient with Refractory Pemphigus Vulgaris: A Lethal Therapeutic Challenge.
Immunosuppressed patients with extensive skin barrier disruption face extraordinary risks for polymicrobial infections. The rapid, sequential emergence of multidrug-resistant (MDR) bacteremia and candidemia in such hosts constitutes a particularly lethal complication with limited therapeutic options.
We report a 74-year-old woman with refractory pemphigus vulgaris (PV), type 2 diabetes mellitus, and chronic obstructive pulmonary disease who developed a cascade of MDR infections over a 14-day hospitalization. Following initial methicillin-resistant Staphylococcus aureus (MRSA) skin colonization, she developed Serratia marcescens bacteremia, subsequently complicated by wound superinfection with carbapenem-resistant Acinetobacter baumannii (CRAB) and multiple Candida species, including the rare yeast Kodamaea ohmeri. Despite sequential antimicrobial escalation-from piperacillin-tazobactam/linezolid to meropenem/amikacin, and finally caspofungin-her condition deteriorated with diabetic ketoacidosis, culminating in the family's decision to pursue discharge with comfort care based on the patient's previously expressed wishes; she died three days later. K. ohmeri demonstrated reduced fluconazole susceptibility (MIC = 8 µg/mL), highlighting the diagnostic and therapeutic challenges posed by emerging fungal pathogens.
This case starkly illustrates the catastrophic potential of rapid, sequential MDR infections in profoundly immunocompromised hosts with skin barrier defects. It underscores the critical importance of early microbiological surveillance, the clinical urgency of dynamic antimicrobial stewardship, and the imperative for multidisciplinary management to navigate the irreconcilable conflict between necessary immunosuppression and life-threatening infection.
We report a 74-year-old woman with refractory pemphigus vulgaris (PV), type 2 diabetes mellitus, and chronic obstructive pulmonary disease who developed a cascade of MDR infections over a 14-day hospitalization. Following initial methicillin-resistant Staphylococcus aureus (MRSA) skin colonization, she developed Serratia marcescens bacteremia, subsequently complicated by wound superinfection with carbapenem-resistant Acinetobacter baumannii (CRAB) and multiple Candida species, including the rare yeast Kodamaea ohmeri. Despite sequential antimicrobial escalation-from piperacillin-tazobactam/linezolid to meropenem/amikacin, and finally caspofungin-her condition deteriorated with diabetic ketoacidosis, culminating in the family's decision to pursue discharge with comfort care based on the patient's previously expressed wishes; she died three days later. K. ohmeri demonstrated reduced fluconazole susceptibility (MIC = 8 µg/mL), highlighting the diagnostic and therapeutic challenges posed by emerging fungal pathogens.
This case starkly illustrates the catastrophic potential of rapid, sequential MDR infections in profoundly immunocompromised hosts with skin barrier defects. It underscores the critical importance of early microbiological surveillance, the clinical urgency of dynamic antimicrobial stewardship, and the imperative for multidisciplinary management to navigate the irreconcilable conflict between necessary immunosuppression and life-threatening infection.