Invasive Pulmonary Aspergillosis: An Emerging Association With Influenza B

Abstract

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Invasive pulmonary aspergillosis (IPA) in critically ill patients is on the rise, but its exact incidence is unclear as the majority of the literature is focused on influenza A co-infection. CASE PRESENTATION: A previously healthy 70 year old male, a farmer by occupation, presented with a flu-like prodrome for 3 days prior to admission. Besides a 40-pack year smoking history, he had no known co-morbidities or risk factors and was found to have Influenza B (IB) and streptococcal pneumonia. His cardio-respiratory status rapidly deteriorated secondary to severe sepsis and ARDS requiring invasive mechanical ventilation. Radiographic imaging of the chest demonstrated multifocal heterogenous opacities of bilateral lung fields with ground glass opacification in the left lower lobe. Sputum gram stain and culture grew Aspergillus fumigatus and serum ß-D glucan assay levels were 193 pg/mL. Bronchoscopy showed mucosal hyperemia with raised pock-like lesions, clustered along the distal right mainstem and right upper lobe bronchi (Figure 1A). There was a non-sloughing, irregular, flat endobronchial lesion adherent to the right upper lobe secondary carina (Figure 1B). The bronchoalveolar lavage culture grew Aspergillus fumigatus and was positive for IB by polymerase chain reaction. The diagnosis of IPA was confirmed with an endobronchial forceps biopsy of the mucosal lesion. Combination therapy with voriconazole and oseltamivir was initiated, along with broad-spectrum antimicrobial coverage. Over twelve days, the clinical course improved with successful extubation and he was discharged home on voriconazole. DISCUSSION: IPA with influenza A has been associated with a rapidly progressive mortality, and recent literature has shown IB to cause equally serious infections.1,2 The earliest report of IPA with IB is from Japan in 2005.3 Disrupted ciliary clearance in the bronchial tree during IB infection predisposes the patient to an invasive fungal infection.3 Interestingly, our patient’s predilection to fungus can also be attributed to extensive smoking and a farming background. Treatment duration with voriconazole can range up to fifty weeks and should be closely monitored with imaging and microbiological evaluation. CONCLUSIONS: IPA with IB is a diagnosis with high morbidity and mortality,1,2 and further investigation is essential to determine its relationship with influenza outbreaks, clinical impact of rapid diagnosis and significance of combination therapy. Reference #1: Park, D.W., et al., Fatal clinical course of probable invasive pulmonary aspergillosis with influenza B infection in an immunocompetent patient. Tuberc Respir Dis (Seoul), 2014. 77(3): p. 141-4. Reference #2: Nulens, E.F., M.J. Bourgeois, and M.B. Reynders, Post-influenza aspergillosis, do not underestimate influenza B. Infect Drug Resist, 2017. 10: p. 61-67. Reference #3: Hasejima, N., et al., Invasive pulmonary aspergillosis associated with influenza B. Respirology, 2005. 10(1): p. 116-9. DISCLOSURE: The following authors have nothing to disclose: Nissy Ann Philip, Christopher Radchenko No Product/Research Disclosure Information