Combination antifungal treatment of pseudomembranous tracheobronchial invasive aspergillosis: a case report

Abstract

Invasive aspergillosis (IA) is increasingly recognized in the intensive care unit (ICU), and new risk factors associated with respiratory colonization or infection by Aspergillus spp. include steroid treatment and chronic lung obstructive disease [1, 2]. In a review of 289 autopsies in the ICU, IA was the leading cause of Goldman class I discrepancy (a missed major diagnosis with major impact on patient management and survival) [3]. The epidemiology of IA indicates an increasing number of infections in immunosuppressed patients/individuals undergoing transplantation of bone marrow, hematopoietic stem cells, or organ transplantations, and those receiving intensive chemotherapy or other immunosuppressive treatments. A broad group of patients who are admitted to ICU also have some form of immunosupppression and may be susceptible to invasive mould infections. For various reasons, figures about the true incidence of IA in ICU are difficult to generate. The most important reason is the difficulty encountered in making a definite diagnosis of IA (lack of sensitivity and specificity with regard to culture and radiology) [4]. Recently, galactomannan (GM) in bronchoalveolar lavage (BAL) fluid appears to be a promising tool for early diagnosis in non-neutropenic critically ill patients and has been associated in proven cases with sensitivity and specificity of 88 and 87%, respectively [5]. Pseudomembranous and obstructive Aspergillus tracheobronchitis are still considered to have a fatal outcome and have been reported in a wide variety of patients [6]. There has been only one report in a patient with diabetes which was treated by deoxycholate amphotericin B (AmB) and subsequent addition of oral itraconazole [7]. In this paper, we report a pseudomembranous and obstructive tracheobronchitis in a diabetic patient successfully treated with caspofungin and AmB.