Abstract
Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020 by the World Health Organization (WHO). Severe COVID-19 is represented with acute respiratory distress syndrome (ARDS) that requires mechanical ventilation. Moreover, recent studies are reporting invasive fungal infection associated with severe COVID-19. It is unclear whether the prescription of immunotherapies such as corticosteroids, or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection itself is risk factor for COVID-19-associated invasive pulmonary aspergillosis (CAPA). Hence, fungal infections present an additional uncertainty in managing COVID-19 patients and further compromise the outcome. Case study: Here we report a case of SARS-CoV-2 complicated by invasive pulmonary aspergillosis (IPA) in a patient with no traditional risk factors for IPA. Admitted to ICU due to ARDS on mechanical ventilation, the patient deteriorated clinically with unexplained increased of fraction of inspired oxygen (FiO2) requirement from 50% to 80%. Investigations showed borderline serum galactomannan, nonspecific radiological findings reported to be atypical for COVID-19, and the respiratory sample grew Aspergillus spp. Main diagnosis: COVID-19 related fungal infection. The patient was treated with antifungal therapy for four weeks. He improved clinically after one week of starting antimicrobial treatment. After a prolonged ICU stay (87 days) due to infection control precaution, he was discharged from the ICU and moved to a long-term facility for further management and support. Conclusions: This case highlights the diagnostic challenge in such cases. and the importance of early recognition of CAPA which can optimize therapy by administration of appropriate antifungal agents that may impact mortality.
Highlights
Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020 by the World Health Organization (WHO)
Case We report the case of a 29-year-old Saudi male security guard known to have diabetes mellitus and chronic kidney disease
This case further supports the association between invasive pulmonary aspergillosis (IPA) and severe SARS-CoV-2 infection
Summary
This case further supports the association between IPA and severe SARS-CoV-2 infection. Aspergillus flavus is responsible for the majority of invasive aspergillosis cases in the kingdom of saudi arabia[14] Our patient had both species isolated from his BAL. The combination of caspofungin and voriconazole has improved the 90-day survival rate especially when used in patients with renal failure or patients with Aspergillus fumigatus infection[26] Our patient had both factors and the choice was to give him dual antifungal therapy especially initially in the disease course. The accuracy of serum galactomannan to diagnose IPA would increase if consecutive tests were performed to override its poor sensitivity in IPA detection in non-neutropenic patients in ICUs. Lastly, repeated chest imaging to assess clinical response of the patient with IPA after completion of antifungal therapy was not done, as the patient was kept on conservative and minimal intervention management
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