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.

• Keywords
• COVID-19, Inhalation injury, Isavuconazole, Mycobiome,
• MeSH
• Antifungal Agents * therapeutic use   MeSH
• COVID-19 * immunology   complications   MeSH
• Adult MeSH
• Fatal Outcome MeSH
• Coinfection microbiology   drug therapy   immunology   MeSH
• Humans MeSH
• Mycoses drug therapy   microbiology   immunology   diagnosis   MeSH
• Nitriles therapeutic use   MeSH
• Burns complications   microbiology   MeSH
• Pyridines therapeutic use   MeSH
• Saccharomycetales genetics   drug effects   immunology   MeSH
• Sepsis drug therapy   microbiology   immunology   MeSH
• Triazoles therapeutic use   MeSH
• Check Tag
• Adult MeSH
• Humans MeSH
• Male MeSH
• Publication type
• Journal Article MeSH
• Case Reports MeSH
• Names of Substances
• Antifungal Agents * MeSH
• isavuconazole MeSH Browser
• Nitriles MeSH
• Pyridines MeSH
• Triazoles MeSH