Chronic cavitary pulmonary aspergillosis in an infant

Abstract

A 7-month-old girl was admitted to the Pediatric Intensive Care Unit at West China Second University Hospital (Chengdu, China) with a recurrent cough for over 3 months, aggravated with fever and dyspnoea for 4 days before presentation. Physical examination revealed rough respiratory sounds, with crackles in both lungs. Blood gas analysis showed low concentrations of partial pressure of oxygen (65·4 mm Hg; normal range, 80–100 mm Hg) and increased lactate (3·4 mmol/L; normal range, 1·0–1·7 mmol/L). Screenings for Mycobacterium tuberculosis, Mycoplasma pneumoniae, and other bacteria and viruses in sputum and bronchoalveolar lavage fluid were negative. Serum (1,3)-β-D-glucan and galactomannan testing showed negative results. A chest x-ray showed bilateral pulmonary inflammation and local consolidation (figure A). Contrast-enhanced chest CT showed a large thick-walled cavity in the right lower lobe (figure B). The patient was treated with intravenous cefoperazone (0·35 g every 8 h) and inhaled acetylcysteine (3 mL every 12 h) for 4 days. High-flow nasal cannula oxygen therapy was implemented first to provide respiratory support to the patient. On day 5, the patient developed haemoptysis (5 mL). Her respiratory status progressively deteriorated and endotracheal intubation was required. Although there was no direct experimental evidence of fungal infection, the diagnosis of chronic cavitary pulmonary aspergillosis was suspected, based on the CT findings and clinical symptoms. The patient was treated with antifungal oral voriconazole (0·07 g every 12 h) for 3 months and her clinical and radiographic condition improved. Finally, the diagnosis of chronic cavitary pulmonary aspergillosis was confirmed by positivity of aspergillus-specific IgG assay.