ASPERGILLUS FUMIGATUS EMPYEMA IN AN IMMUNOCOMPROMISED PATIENT WITH RHEUMATOID ARTHRITIS

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 is a rare entity (less than 1 percent of all cases) with Candida spp. being the most common etiological agents and only a few cases due to Aspergillus spp (1). CASE PRESENTATION: A 74-year-old male with history of rheumatoid arthritis on maintenance prednisone and methotrexate presented with progressive exertional shortness of breath and productive cough for 3 months. Chest X-ray showed a large left pleural collection with air-fluid level and thick wall. Computed tomography (CT) of the chest showed a large pleural loculation with an air fluid level surrounded by thickened wall, consolidation of the left lower lobe, and scattered tree-in-bud opacities bilaterally. A small right pleural effusion with multiple benign appearing pulmonary nodules was also noted. Video-assisted thoracoscopic surgery (VATS) with decortication was done. Pleural biopsy showed a dense mat of branching, septated fungal hyphae involving necrotic pleura. Pleural fluid cultures grew Aspergillus fumigatus. IV liposomal amphotericin was started, caused hypotension, was changed to IV voriconazole which led to acute liver injury and was eventually treated with micafungin. Repeat cultures from thoracostomy drainage grew Streptococcus viridans and Neisseria flava. They were suspected to have seeded from a bronchopleural fistula and IV piperacillin-tazobactam was given for coverage. The hospital course was complicated by left sided pneumothorax post-VATS requiring reinsertion of chest tube, atrial fibrillation with rapid ventricular rate, dysphagia and right sided pleural effusion requiring diagnostic thoracentesis (exudative fluid with negative culture). Patient requested discontinuation of medical therapy and transition to comfort measures due to his extended hospital stay. He was eventually transferred to hospice. DISCUSSION: Among the Aspergillus empyema cases, A. fumigatus is isolated most often, though other spp., such as A. flavus and A. terreus, have also been implicated (2). Fifty percent of such cases are polymicrobial. Risk factors include immunocompromised state and conditions predisposing to bronchopleural fistula (tuberculosis, sarcoidosis, cavitary pneumonia, thoracic surgery, pneumonectomy and lung transplantation). Diagnosis is made from pleural fluid culture or pleural biopsy stains showing characteristic hyphae. Pleural fluid is generally turbid with high protein, low glucose, increased neutrophils and galactomannan. Treatment is combined surgical (drainage of the pleural cavity, necrotic tissue resection and closure of bronchopleural fistula) and prolonged systemic antifungal therapy with triazoles (first line) or echinocandins (salvage therapy for treatment failure or tolerability concerns) (3). CONCLUSIONS: Aspergillus empyema is a rare but highly morbid entity that should be considered in immunocompromised hosts and requires surgical and prolonged medical management. Reference #1: Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: an emerging clinical entity. Chest. 2000;117(6):1672. Reference #2: Albelda SM, Gefter WB, Epstein DM, Miller WT. Bronchopleural fistula complicating invasive pulmonary aspergillosis. Am Rev Respir Dis. 1982 Jul;126(1):163-5 Reference #3: Bonatti H, Lass-Floerl C, Angerer K, Singh N, Lechner M, Stelzmueller I, Singh R, Schmid T, Geltner C. Successful Management of Post pneumonectomy Aspergillus pleural empyema by combined surgical and antifungal treatment with voriconazole and caspofungin. Mycoses. 2010 Sept; 53(5) 448-54 DISCLOSURES: No relevant relationships by Amit Rout, source=Web Response No relevant relationships by Adrian Sarzynski, source=Web Response No relevant relationships by Sahib Singh, source=Web Response