INVASIVE PULMONARY ASPERGILLOSIS SUPERINFECTION IN A CRITICALLY ILL PATIENT WITH INFLUENZA A AND LIMITED CORTICOSTEROID EXPOSURE

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: It is our aim to highlight less well-recognized risk factors for invasive pulmonary aspergillosis(IPA). Early recognition of risk factors can raise clinical suspicion for Aspergillus superinfection so that appropriate and prompt therapy can be initiated potentially reducing morbidity and mortality. CASE PRESENTATION: A 69 year old female with a history of diabetes mellitus type 2, pancreatic cancer in remission status post remote Whipple procedure and COPD presented with dyspnea, wheezing and non-productive cough. She quickly deteriorated and was admitted to the ICU with hypoxic respiratory failure. One week prior to admission, she had completed a five day corticosteroid steroid burst for COPD exacerbation. CT chest demonstrated bilateral ground glass alveolar opacities on a background of stable centrilobular emphysema. Influenza A molecular assay was positive and Oseltamivir therapy was initiated. Despite receiving broad spectrum antibiotics and oseltamivir she remained febrile, required more oxygen and declined. Repeat thoracic imaging demonstrated worsening of the infiltrates and bronchoalveolar lavage specimens isolated Aspergillus fumigatus prompting immediate voriconazole therapy. DISCUSSION: Classically, IPA has been regarded as an ailment of those with weakened host immune systems such as in hematological malignancy, solid organ transplant and neutropenia. Influenza A is known to lay the framework for bacterial superinfections, but predisposing patients to invasive fungal organisms has only garnered significant attention within the last decade. Abbott et al. documented a case of invasive aspergillosis plaguing a previously immunocompetent individual acutely infected with Influenza in 1952, but it was not until 2018 that Schauwvlieghe et al identified Influenza as an independent risk factor for IPA in patients admitted to the ICU with pneumonia. Further, those receiving prolonged, high-dose glucocorticoid therapy have also been shown to be at greater risk for development of IPA, but the threshold of glucocorticoid exposure remains unclear. In 2012, Wauters et al demonstrated that steroid administration within seven days of presentation was a significant risk factor for development of Aspergillus; however, no corticosteroid dose risk relationship could be identified. Both corticosteroid exposure and Influenza A infection predispose patients to Aspergillus superinfection, on their own, but additional investigation is necessary to determine the threshold of corticosteroid exposure as well as the concurrent additive risk of Aspergillus infection when these two factors are combined. CONCLUSIONS: Knowledge of risk factors and thus the ability to identify patients at increased risk for Aspergillus superinfection, earlier in the course of hospitalization, may lead to a better determination of who warrants empiric antifungal coverage with the end result being improved morbidity and mortality. Reference #1: Schauwvlieghe AFAD, Rijnders BJA, Philips N, Verwijs R, Vanderbeke L, Van Tienen C, Lagrou K, Verweij PE, Van de Veerdonk FL, Gommers D, Spronk P, Bergmans DCJJ, Hoedemaekers A, Andrinopoulou ER, van den Berg CHSB, Juffermans NP, Hodiamont CJ, Vonk AG, Depuydt P, Boelens J, Wauters J; Dutch-Belgian Mycosis study group. "Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study". Lancet Respir Med. 2018 Oct;6(10):782-792. Reference #2: Lewis R, Kontoyiannis, D. "Invasive aspergillosis in glucocorticoid-treated patients". Medical Mycology, Volume 47, Issue Supplement 1, 1 January 2009, Pages S271–S281 Reference #3: Wauters J, Baar I, Meersseman P, Meersseman W, Dams K, De Paep R, Lagrou K, Wilmer A, Jorens P, Hermans G. "Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study". Intensive Care Med. 2012 Nov;38(11):1761-8. DISCLOSURES: No relevant relationships by Median Ali, source=Web Response No relevant relationships by James Gleason, source=Web Response No relevant relationships by Aleksandra Kozlova, source=Web Response No relevant relationships by Shawn Marein, source=Web Response No relevant relationships by Avneek Singh Sandhu, source=Web Response