P0420 / #1665: PNEUMOPERICARDIUM, PNEUMOTHORAX, AND PULMONARY HEMORRHAGE FROM INVASIVE ASPERGILLOSIS

Abstract

Aims & Objectives: Identification of an unusual presentation of invasive pulmonary aspergillosis (IPA). Methods: Case report with review of literature Results: A 12-year-old female with pre-B-cell leukemia and recent pancreatitis presented to our Pediatric ICU for acute respiratory failure secondary to IPA identified through serology. In spite of aggressive antifungal therapy, she developed pneumopericardium (PPC), followed by pneumothorax (PTX) and pulmonary hemorrhage (PH) 6 and 11 days later, respectively. She ultimately died of cardiopulmonary arrest from hemorrhagic shock. At autopsy, her pericardium was found to be intact without fistula to the adjacent aspergillomas. Anatomic and histologic evaluation of the heart was unremarkable. There was no microbial growth from the small volume of pericardial fluid recovered. Conclusions: IPA develops almost exclusively in immunocompromised patients. Association with PPC, PTX, or PH has been reported. These severe complications occur during rapid granulocyte recovery. Percutaneous biopsy performed after the development of PTX revealed Aspergillus terreus, an uncommon cause of IPA; treatment of choice, voriconazole, was initially avoided due to her recent pancreatitis. PPC associated with IPA can result from direct infection of endomyocardial or pericardial tissue, or by fistula formation; unusual to this case was the lack of an obvious fistula and no obvious tissue involvement. To our knowledge this is the first report of IPA causing the sequential development of PPC, PTX, and PH. Diagnostic and therapeutic interventions may increase morbidity and mortality. Treatment may be limited by patient comorbidities.