Photo Quiz: Peripherally Inserted Central Catheter-Associated Bloodstream Infection in an 87-Year-Old Patient

An 87-year-old male was hospitalized for gastrointestinal (GI) bleeding. He had a medical history significant for heart failure with reduced ejection fraction on milrinone infusion through a peripherally inserted central catheter (PICC) line, atrial fibrillation, and coronary artery disease. At initial presentation, he had low hemoglobin of 5.9 g/dL (range, 12.2 to 16.4 g/dL) and was treated with multiple packed red blood cell (PRBC) transfusions. In addition, the patient was hypotensive with a blood pressure of 93/56 mm Hg. As a part of the shock workup, two sets of blood cultures were collected on hospital day 1 (HD1). The broad-spectrum intravenous (i.v.) antibiotics were given based on his history of PICC-associated infections but stopped after blood cultures remained negative for 24 h. A colonoscopy revealed a single nonbleeding angioectasia, for which clips were applied. On HD6, an aerobic blood bottle from one set of blood cultures turned positive, with the Gram stain reported as budding yeast with pseudohyphae (Fig. 1A). Since the patient was asymptomatic, two more sets of blood cultures followed to rule out contamination, and one out of these two sets was collected through the PICC line. On HD8, the patient was weaned off milrinone, his PICC was removed, and he was discharged. However, blood and chocolate agar plates incubated at 35°C after 48 h showed white fuzzy colonies indicative of mold. The positive blood bottle was retapped and plated on potato dextrose (PDA) and Sabouraud (SAB) agars and incubated at 30°C and 37°C. After 24 h, growth was observed only on the plates incubated at 30°C. Meanwhile, another aerobic bottle from the second set of blood cultures collected through the PICC line at HD6 turned positive after 60 h of incubation. This time, hyphae were reported from the Gram stain with representative fungal elements shown in Fig. 1B. A lactophenol cotton blue tape mount of the organism is shown in Fig. 1C. The patient was readmitted on i.v. voriconazole at 6 mg/kg of body weight every 12 h (q12h) for 24 h and given posaconazole at 300 mg twice for 1 day based on the organism identification. The next day, he was discharged on oral posaconazole at 300 mg daily for 14 days. The patient was doing well at the 1-month follow-up visit.