Aspergillus nidulans: A Rare Cause of Invasive Pulmonary Aspergillosis Resulting in Diffuse Alveolar Hemorrhage

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Invasive Pulmonary Aspergillosis (IPA) is an important source of morbidity and mortality in patients who are immunosuppressed. In the majority of cases, A. fumigatus is the causative species. We present a case of non-fumigatus IPA in patient on immunosuppressive therapy for a history of solid organ transplant. CASE PRESENTATION: Our patient is a 25 year old African American female with a history of cirrhosis secondary to autoimmune hepatitis for which she received a liver transplant in 2012 and had been maintained on immunosuppressive therapy with mycophenolate, prednisone, and tacrolimus. She initially presented to an outside hospital with complaints of fever, cough, and dyspnea. Two weeks prior to that she had been diagnosed with acute on chronic rejection, recurrent cirrhosis, and her prednisone dose was increased. She rapidly decompensated and required intubation. She was then transferred to our institution. Upon arrival copious blood was aspirated from the ET tube. Bronchoscopy revealed a white exudate with intermixed hemorrhage. Lavage culture was positive for A. nidulans. Serum (1-3)-Beta-D-Glucan and BAL/Serum aspergillus antigen ratio were markedly elevated. Rheumatologic workup included a skin biopsy of a rash that developed which was consistent with lupus. She was maintained on antibiotics, antifungals, and immunosuppressives and eventually was discharged to rehab. DISCUSSION: IPA mortality is highest amongst those who have had stem cell transplants or liver transplants. A. fumigatus is the most common causative agent and has been documented to occur in up to 90% of isolates. A. nidulans primarily affects patients with G6PD deficiency. In that population, hyphal angioinvasion is not seen. To our knowledge, only 1 other case of diffuse alveolar hemorrhage has been reported as caused by A. nidulans. Many factors contributed to her respiratory failure from DAH including underlying coagulopathy from cirrhosis, a new diagnosis of lupus, and pre-disposition to IPA from immunosuppression. A. nidulans has occurred more frequently in patients on anti-fungal prophylaxis which may suggest the existence of higher levels of resistance. Increased usage of anti-fungals as prophylaxis, as well as, increasing numbers of stem cell and solid organ transplants may lead to an increased number of cases of IPA and a change in the spectrum of pathology and species encountered. CONCLUSIONS: Atypical aspergillus species are uncommon but are a potential source of significant morbidity and mortality. Increased use of prophylactic anti-fungals may lead to increased resistance in the future. Reference #1: Liu, X., et al. (2011). Invasive fungal infections in liver transplantation. Int J Infect Dis 15(5):e298-304. Reference #2: Henriet S. et al. (2012). Aspergillus nidulans and Chronic Granulomatous Disease: A Unique Host-Pathogen Interaction. J Infect Dis. 206(7):1128-1137. Reference #3: Dimopoulos, G., et al. (2012). Invasive aspergillosis in the intensive care unit. Ann N Y Acad Sci 1272:31-39. DISCLOSURE: The following authors have nothing to disclose: Peter Rattner, Anne Sutherland No Product/Research Disclosure Information