ASPERGILLUS EMPYEMA IN A LUNG TRANSPLANT PATIENT

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fungal empyema thoracis is an uncommon entity with reported mortality rates as high as 73% [1]. Here we report a case of aspergillus empyema with associated cutaneous lesion in a lung transplant patient. CASE PRESENTATION: A 70 year old man who had undergone left lung transplant 5 years prior for chronic hypersensitivity pneumonitis, on immune suppressive therapy with tacrolimus, mycophenolate and prednisone presented with 3 months of weight loss, generalized weakness and confusion. He noted a stable chronic cough productive of clear phlegm, without dyspnea, hemoptysis, fever or night sweats. Approximately 3 months prior to presentation, while undergoing treatment for squamous cell carcinoma of the scalp, he had an anterior chest wall mass excised, histopathology notable for severe acute inflammation and narrow septate hyphal elements. Serum and bronchoalveolar lavage fluid galactomannan levels at that time were not detected, and treatment with systemic antifungals was deferred. On hospitalization, he was well-appearing with normal oxyhemoglobin saturation on room air. Limited bedside ultrasound examination demonstrated a large multi-loculated pleural effusion. Computed tomography imaging revealed severe traction bronchiectasis and fibrosis of native right lung and a large right sided pleural effusion. Diagnostic thoracentesis yielded a hazy yellow exudate with a pH 6.99, LDH of 1462 U/L, total protein 2.2 g/dL, and glucose 256 mg/dL. Fluid culture revealed 2+ Aspergillus fumigatus, consistent with a diagnosis of aspergillus fumigatus. He underwent treatment with oral isavuconazole and intrapleural tPA/dornase alpha via a pleural pigtail catheter. Unfortunately, the effusion persisted; surgical options were reviewed with patient, who elected to defer surgery and discharge home with hospice. DISCUSSION: Aspergillus empyema thoracis is an uncommon disease which mostly occurs in patients with established empyema or bronchiectectatic cavities and a bronchopleural or pleurocutaneous fistula [2]. In our case, early manifestations of invasive aspergillosis were subtle, and diagnosis elusive until the disease was advanced. CONCLUSIONS: Fungal empyema thoracis is an important differential consideration for pleural effusion in patients with chronic immune suppression, solid organ or hematologic malignancy. Mortality for this condition is high, particularly if not recognized and treated appropriately. Reference #1: Ko, SC et al. Fungal empyema thoracis: an emerging clinical entity. Chest, 2000; 117(6):1672-8. Reference #2: Zhang, W. et al. Pleural aspergillosis complicated by recurrent pneumothorax: a case report. J Med Case Rep, 2010. 4: p 180. DISCLOSURES: No relevant relationships by Nicholas Braus, source=Web Response No relevant relationships by Timothy Rowe, source=Web Response