Patients with burn injury and inhalation injury are highly susceptible to infectious complications, including opportunistic pathogens, due to the loss of skin cover and mucosal damage of respiratory tract as well as the disruption of homeostasis. This case report, a 34-year-old man suffered critical burns, provides the first literature description of triple-impact immunoparalysis (critical burns, inhalation injury, and SARS-CoV-2 infection), leading to a lethal multifocal infection caused by several fungi including very rare environmental representatives Metschnikowia pulcherrima and Wickerhamomyces anomalus. The co-infection by these common environmental yeasts in a human is unique and has not yet been described in the literature. Importantly, our patient developed refractory septic shock and died despite targeted antifungal therapy including the most potent current antifungal agent-isavuconazole. It can be assumed that besides immunoparalysis, effectiveness of therapy by isavuconazole was impaired by the large distribution volume in this case. As this is a common situation in intensive care patients, routine monitoring of plasmatic concentration of isavuconazole can be helpful in personalization of the treatment and dose optimization. Whatmore, many fungal species often remain underdiagnosed during infectious complications, which could be prevented by implementation of new methods, such as next-generation sequencing, into clinical practice.

CEITEC Central European Institute of Technology Brno University of Technology Purkynova 656 123 Brno Czech Republic

Department of Burns and Plastic Surgery Faculty of Medicine Institution Shared With University Hospital Brno Masaryk University Jihlavska 20 Brno Czech Republic

Department of Clinical Microbiology and Immunology University Hospital Brno Jihlavska 20 Brno Czech Republic

Department of Forensic Medicine Institutions Shared With St Anne's Faculty Hospital Faculty of Medicine Masaryk University Pekarska 664 53 Brno Czech Republic

Department of Internal Medicine Haematology and Oncology Faculty of Medicine Institution Shared With University Hospital Brno Masaryk University Jihlavska 20 Brno Czech Republic

Department of Pathology Faculty of Medicine Institution Shared With University Hospital Brno Masaryk University Jihlavska 20 Brno Czech Republic

RECETOX Faculty of Science Masaryk University Kotlarska 2 Brno Czech Republic

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