Disseminated histoplasmosis is usually associated with immunosuppressive conditions like AIDS. People with respiratory distress syndrome secondary to SARS-CoV-2 pneumonia are vulnerable to bacterial infections. Additionally, coinfection with fungal pathogens should be considered as a differential diagnosis even in immunocompetent patients who remain on mechanical ventilation secondary to COVID-19. The case presents a 61-year-old immunocompetent man, admitted to the medical ward due to COVID-19 pneumonia. Despite appropriate therapy, the patient required transfer to the intensive care unit for invasive mechanical ventilation. He remained critically ill with worsening respiratory failure. Two weeks later, coinfection by disseminated histoplasmosis was detected. After immediate treatment with amphotericin B and itraconazole, the patient tolerated weaning from mechanical ventilation until extubation. Awareness of this possible fungal coinfection in immunocompetent patients is essential to reduce delays in diagnosis and treatment, and prevent severe illness and death.

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Immune checkpoint inhibitors have transformed the treatment of cancer. Nonetheless, multiple immune-related adverse events have been reported, including checkpoint inhibitor colitis. Severe colitis can be complicated by ileus, megacolon, intestinal perforation, and death. Current appropriate treatment includes steroids, followed by antitumor necrosis factor biologic therapy, infliximab. Alternatively, vedolizumab and fecal microbiota transplantation have reported efficacy for refractory cases. In this study, we present the first case report of a patient with steroid-refractory checkpoint inhibitor-induced colitis due to pembrolizumab for Stage IV anaplastic thyroid carcinoma successfully treated with ustekinumab after failure of infliximab, vedolizumab, and fecal microbiota transplantation. This may lead to a better understanding of treatment options for refractory checkpoint inhibitor colitis.

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