Case Of Invasive Pulmonary Aspergillosis Research Articles

Invasive pulmonary aspergillosis in a 4-year-old male following submersion in a manure pond.

Invasive pulmonary aspergillosis (IPA) is uncommon in immunocompetent patients, but rare cases have been described after nonfatal drowning, particularly in contaminated water sources. Given subacute disease manifestations, diagnostic difficultiesand the rapidly progressive nature of this organism, its mortality rate approaches 50%. Clinicians must rely on nonculture-based biomarkers and imaging to inform early diagnosis. There are currently no recommendations regarding diagnostics or empiric therapy for mold infections in near-drowning patients. We report a fatal case of IPA in a 4-year-old male following submersion in a manure pond. Early serum biomarkers and empiric voriconazole should be strongly considered in all patients after near-drowning in contaminated water sources.

Fatal Case of Invasive Pulmonary Aspergillosis Post COVID-19 Pneumonia Due to Aspergillus Niger

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A rare case of invasive pulmonary aspergillosis in an immunocompetent individual

Invasive aspergillosis is a highly lethal opportunistic infection that poses a significant threat to immunocompromised patients. In these patients, the incidence of the disease is increasing, and the mortality rates remain high, so early diagnosis and treatment are very important to improve patient survivability. However, there are few described cases of invasive aspergillosis in immunocompetent patients without any type of comorbidity. We present the case of a 44-year-old immunocompetent woman who presented with a history of productive cough and fever for 1 week. Initially, the clinical and radiological presentation pointed to an infection. Several courses of antibiotics were administrated, with no improvement. Bronchofibroscopy with bronchial biopsies was performed and the bronchoalveolar lavage was negative for all investigations (including fungi). The patient started presenting massive hemoptysis, unresponsive to non-invasive therapies or bronchial artery embolization, requiring pneumonectomy as a life-saving procedure. Definitive diagnosis was made by histological demonstration of tissue invasion by the fungus and growth of Aspergillus in culture. Despite aggressive treatment, the patient is currently under antifungal therapy and respiratory kinesiotherapy, showing great clinical, analytical and radiological improvement. This case emphasizes the importance of maintaining a high index of suspicion and also to remember that invasive aspergillosis can also affect immunocompetent individuals.

Invasive pulmonary aspergillosis presenting with tracheopleural fistula in a pediatric patient with a history of rhabdomyosarcoma.

Invasive aspergillosis is a known complication in patients with hematologic malignancies. Tracheopleural fistulas are very rare and reported in immunocompromised adults. We present a case of invasive pulmonary aspergillosis with tracheopleural fistula in a pediatric patient with a history of rhabdomyosarcoma and macrophage activation syndrome. This case highlights the importance of recognizing life-threatening fungal infections and coordinating surgical subspecialities for patient care.

Air crescent sign: typical case of invasive pulmonary aspergillosis.

Air crescent sign: typical case of invasive pulmonary aspergillosis.

A Case of Invasive Pulmonary Aspergillosis Resulted from the Treatment of Chronic Eczema

This was an advanced male (87-year-old) with refractory chronic eczema for over 40 years, based on his allergic constitution, accompanied with chronic kidney disease due to primary hypertension (CKD, phase 3). It was so diffi cult to tolerate the severe itching that the glucocorticoids (GC) had to be applied to it, but some new-onset respiratory symptoms, such as cough, dyspnea after exertion etc., occurred to this patient. Some classical IPA images were found on his pulmonary CT scanning, which were further comfirmed by the positive findings of GM-test, and then a final diagnosis of IPA was accordingly established. Unfortunately, a persistent fever emerged after starting an antifungal therapy to the patient, and his IL-2 level was detected to be superhigh. As a response to allergic fever, GC was carefully given intravenously again to treat it, and it turned out to be totally improved since then; suggesting that systemic thinking (integrated with the other clinical evidences) is essential to diagnose IPA, and GC can also be used to improve its symptoms with the existence of antifungal therapy.

TUMOR NECROSIS FACTOR (TNF) ALPHA INHIBITORS, ASPERGILLOSIS, AND GALACTOMANNAN: THE PERILS OF BEING MISLED BY AN INSENSITIVE TEST

TUMOR NECROSIS FACTOR (TNF) ALPHA INHIBITORS, ASPERGILLOSIS, AND GALACTOMANNAN: THE PERILS OF BEING MISLED BY AN INSENSITIVE TEST

A Case of Invasive Pulmonary Aspergillosis vs. Pulmonary Aspergilloma in Immunocompromised Patient With Preexisting Lung Cavity

Subacute invasive aspergillosis (SAIA) occurs in immunocompromised patients and/or patients with preexisting pulmonary pathology. An aspergilloma is a fungus ball that occurs in preexisting lung cavities and can be relatively asymptomatic without tissue invasion. In contrast to an aspergilloma, SAIA invades local tissue and parenchyma, resulting in tissue necrosis. We present a case of a 68-year-old immunocompromised female with a past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), stage IIIA adenocarcinoma, and a preexisting pulmonary cavity with chronic invasive aspergillosis vs. pulmonary aspergilloma treated with oral (PO) voriconazole. This case demonstrates that invasive aspergillosis should be considered in the differential diagnosis of any pulmonary lung lesion showing tissue invasion and expansion in an immunocompromised patient.

Rare cases of systemic phaeohyphomycoses caused by Bipolaris species as a Post SARS-COV 2 sequelae

PurposeThe deadly second wave of COVID-19 brought an unprecedented rise of cases of associated invasive fungal infections. In this study we present two rare cases of systemic phaeohyphomycoses by Bipolaris species as a Post SARS-COV 2 sequelae, which may usually be neglected as contaminants.Methods & MaterialsRetrospective study of 1150 specimens received from patients with a high index of clinical suspicion of invasive fungal infections from April 2021 to June 2021 to identify cases of invasive phaehyphomycoses among post COVID patients. Diagnosis of phaeohyphomycoses was established on microbiological evidence including microscopy and culture, and radiological evidence along with supporting clinical features. The diagnosis of phaeohyphomycoses was confirmed when dark pigmented thin septate hyphae with or without spores were demonstrated in aseptically aspirated fluid or tissue specimen with pure culture isolate of velvety dark, brownish black flat colonies on Sabouraud dextrose agar at 25°C.ResultsDuring the study period, two cases were confirmed as invasive phaeohyphomycoses caused by Bipolaris spicifera phenotypically. The first case was of invasive fungal sinusitis and second of invasive pulmonary phaeohyphomycoses. Overall incidence rate was 0.55% (2/364). Both cases were post COVID, with history of COVID 2-3 weeks before current presentation and hospitalisation with oxygen support for the same, uncontrolled diabetes mellitus (HbA1C: 11 & 8 respectively), and hypothyroidism. First case was initially treated as of mucormycosis, considering her clinical presentation and high index of suspicion with several similar cases reported in our area. He was managed with Amphotericin B along with surgical debridement. Second case was suspected as case of invasive pulmonary aspergillosis and was managed with voriconazole initially and later started on itraconazole after laboratory confirmation. Due to initial false diagnosis in our cases, patients were subjected to long course of amphotericin B and voriconazole respectively, whereas it could have been managed with itraconazole which has far lesser side effects.ConclusionHigh index of suspicion is required to confirm invasive phaeohyphomycoses as dematiaceous fungi are often contaminants or commensals. Correct and timely diagnosis is necessary for adequate management of invasive phaeohyphomycoses cases.

Subacute invasive pulmonary aspergillosis

Subacute invasive pulmonary aspergillosis (IPA) is an indolent cavitating infectious process which can mimic other chronic lung infections such as tuberculosis. This usually occurs in mildly immunosuppressed individuals and clinically evolves over weeks to months. Radiological presentation is in the form of thick-walled cavity with or without mycetoma, fibrosis, and pleural invasion. Here, a case of subacute IPA in a middle-aged female with rheumatoid arthritis is reported, highlighting a rare radiological appearance.

Invasive pulmonary aspergillosis in an immunocompetent, heavy smoker of marijuana with emphysema and chronic obstructive pulmonary disease

Heavy marijuana smoking has been described a predisposing cause of invasive pulmonary aspergillosis in immunocompromised subjects. This article describes a case of invasive pulmonary aspergillosis in an immunocompetent patient with chronic obstructive pulmonary disease, who was not on maintenance oral corticosteroids and who had been smoking 30 joints per day and developed necrotizing pneumonia. Bronchoalveolar lavage culture was positive for Aspergillus Fumigatus. In the absence of clinical-radiographic response to broad spectrum antibiotic and any other positive culture, treatment with voriconazole was initiated, with resolution of lung cavities and airspace opacities and return to baseline clinical status. Repeat bronchoalveolar lavage was negative for Aspergillus Fumigatus. Invasive pulmonary aspergillosis may be considered in the differential diagnosis of necrotizing pneumonia in heavy smokers of marijuana with chronic lung disease.

A Case of Invasive Pulmonary Aspergillosis in an Immunocompetent Patient Diagnosed by EBUS-TBNA, Misdiagnosed as Lung Cancer.

A Case of Invasive Pulmonary Aspergillosis in an Immunocompetent Patient Diagnosed by EBUS-TBNA, Misdiagnosed as Lung Cancer.

A case of invasive pulmonary aspergillosis during treatment for acute exacerbation of interstitial lung disease.

Prolonged immunosuppressive therapy is a risk factor for invasive pulmonary aspergillosis. We report a case of a 79-yearold man who underwent immunosuppressive therapy with methylprednisolone and cyclosporine for an acute exacerbation of interstitial lung disease. Ten days after initiation of immunosuppressive therapy, the patient reported night sweats and purulent sputum, and chest computed tomography scan revealed consolidation. He was diagnosed with invasive pulmonary aspergillosis, and required vasopressor support with oxygen therapy. After the administration of voriconazole and the modulation of immunosuppressive therapy, his condition improved. Short-term immunosuppressive therapy can also induce invasive pulmonary aspergillosis.

Aspergillus pseudodeflectus: a new human pathogen in liver transplant patients

BackgroundLiver transplant recipients are at high risk of developing invasive aspergillosis and in particular by Aspergillus fumigatus which is the most commonly encountered species in this population. Other non-fumigatus Aspergillus species with reduced susceptibility to antifungal drugs can also be involved. Accurate identification associated to antifungal susceptibility testing is essential for therapy adjustment. We report a case of invasive pulmonary aspergillosis due to Aspergillus pseudodeflectus in a liver transplant recipient. To our knowledge, this is the first reported case of invasive aspergillosis due to this species with a reduced susceptibility to azoles.Case presentationA 64 year-old woman with drug-induced fulminant hepatitis underwent liver transplantation. Prophylactic treatment with caspofungin was introduced due to aspergillosis risk factors consisting in hemodialysis and fulminant hepatitis. Six weeks after transplantation, CT scan showed a right pulmonary opacity associated with an increase of galactomannan (index 5.4). Culture of BAL grew with several colonies of Aspergillus sp. The diagnosis of invasive aspergillosis was probable according to the EORTC criteria. The antifungal susceptibility tests (Etest®) revealed low MICs to echinocandins and amphotericin B) but high MICs to azoles. After these results, voriconazole was switched to liposomal amphotericin B. The patient died one month after diagnosis from a refractory septic shock with multiple organ failure. A molecular identification of isolate, based on partial β-tubulin and calmodulin genes, was performed and identified A. pseudodeflectus.ConclusionsOur case raises the question of pathogenicity of this species, which belongs to Aspergillus section Usti and is genetically and morphologically very close to Aspergillus calidoustus that was previously reported in human transplant recipients.

360. Breakthrough Invasive Pulmonary Aspergillosis During Isavuconazole Prophylaxis in Patients with Hematologic Malignancies: A Single-Center Experience

BackgroundIsavuconazole (ISA) is an attractive candidate for prophylaxis against invasive mould infections (IMIs) due to its broad-spectrum activity, ease of dosing, favorable side-effect profile, and limited drug–drug interactions. Clinical experience using ISA prophylaxis in high-risk patients is lacking. We describe our experience using ISA as first-line primary prophylaxis in select patients with hematologic malignancies and hematopoietic cell transplant (HCT) recipients over a 13-month period.MethodsWe conducted a retrospective review of adults with hematologic malignancies and HCT recipients who received ≥7 days of uninterrupted ISA primary prophylaxis between September 1, 2016 and September 31, 2017. Breakthrough IMIs were documented through chart review and classified as probable or proven according to standard criteria. The study was approved by the OHSU IRB.ResultsA total of 135 patients received 184 courses of ISA prophylaxis for AML (N = 100), GVHD (N = 36), “high-risk HCT” (≥14 days neutropenia immediately prior to HCT; N = 25), and other indications (N = 23). Ten cases of proven/probable breakthrough IMIs were identified (invasive pulmonary Aspergillosis (IPA) = 6, Mucorales = 2, Fusarium = 2). Four cases of breakthrough IPA occurred during prophylaxis for AML, and two occurred during prophylaxis after high-risk HCT. All breakthrough IPA occurred during prolonged neutropenia (median 46 days, range 16–181). The median duration of ISA prophylaxis prior to breakthrough IPA was 15 days (range 10–37). The median serum ISA trough level at breakthrough IPA was 3.7 μg/mL (range 3.1–6.3). During this same time period, there was no breakthrough IPA during 101 courses of voriconazole or posaconazole (POS) prophylaxis in similar patients. Only one case of breakthrough IPA occurred during 244 courses of POS prophylaxis in the 18 months prior to the introduction of ISA prophylaxis. Due to the higher than expected rate of breakthrough IPA, POS replaced ISA as first-line primary prophylaxis in October 2017. Since then there have been no cases of breakthrough IPA on POS prophylaxis.ConclusionOur institutional experience indicates that additional studies are needed to determine the role of ISA for prophylaxis in certain high-risk hematologic malignancy patients.Disclosures J. S. Lewis II, Merck: Consultant, Consulting fee

2040. Clinical Application of Aspergillus Lateral Flow Device (AspLFD) in Bronchoalveolar Lavage (BAL) Fluid of Patients with Classic Risk Factors for Invasive Pulmonary Aspergillosis (IPA)

BackgroundIPA causes high morbidity and mortality in immunocompromised patients, but diagnosis remains challenging. A newly formatted AspLFD targets specific Aspergillus antigen JF5, but reported results for this test are variable. We evaluated the performance characteristics of this new AspLFD in BAL fluid of patients with IPA.MethodsSamples tested were from patients with classic risk factors for IPA defined by EORTC/MSG criteria and that had been prospectively banked in our BAL repository. Each case of IPA identified was matched to two high-risk control patientst without IPA or other invasive fungal infection. Samples were thawed, vortexed, centrifuged, and 100 μL of supernatant was applied to the AspLFD. Results were interpreted at 15 minutes as +, ++, +++, or negative by three independent, blinded observers. Test characteristics, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.ResultsSamples from 14 patients with proven/probable IPA by EORTC/MSG criteria and 28 control patients without IPA were tested. Median age was 58 (range 22–87); 28 were men. Age and gender distribution were similar between cases and controls. Among IPA cases, 9 were on T cell depleting agents, 4 on high-dose steroids, and 3 had prolonged neutropenia. Among non-IPA controls, risk factors were T-cell depleting agents (17), high-dose steroids (11), and stem cell transplant (2). Of the 14 patients with IPA, AspLFD was positive in 3, negative in 9; in 2, the internal control line did not display and these were considered invalid. Of 6 patients receiving an azole, three had a positive AspLFD test. AspLFD was negative for all 28 BAL in the non-IPA group. AspLFD showed low sensitivity (25%) and high specificity (100%); PPV was 100% and NPV was 75%. Accuracy of the test was 77.5%.ConclusionA positive AspLFD test in BAL of patients with classic risk factors for IPA could be useful for ruling in proven/probable IPA because of its high specificity. However, the use of AspLFD as a screening test for IPA is limited by its poor sensitivity.Disclosures All authors: No reported disclosures.

INVASIVE PULMONARY ASPERGILLOSIS IN AN IMMUNOCOMPROMISED PATIENT: A CASE REPORT

SESSION TITLE: Chest Infections 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: We present a case of invasive pulmonary aspergillosis in an immunocompromised patient, along with supportive diagnostic results that include serum biomarker assays, computed tomography imaging, and bronchoalveolar lavage fluid analysis. CASE PRESENTATION: A 47-year-old HIV/AIDS patient, non-compliant to antiretroviral therapy, presented with acute non-specific symptoms of malaise, mild productive cough, and subjective fever with chills, without hemoptysis or chest pain. He had recently visited other hospitals prior to this visit and importantly was not diagnosed with Aspergilloma. During this hospitalization, his low grade intermittent fever was resistant to empirical broad -spectrum antibiotic therapy. He was noted to have marked immunosuppression with 1 CD4+ lymphocytes/mm3 and a high viral RNA load. In addition, imaging studies revealed the presence of a thick walled cavitary mass at the right lung apex with centrilobular nodules consistent with aspergilloma, along with patchy ground glass opacities surrounding an alveolar infiltrate, consistent with the “Halo Sign” of invasive aspergillosis. Tuberculosis was ruled out. Serum aspergillus titers were positive. Bronchoscopy with bronchoalveolar lavage revealed dark fluid with suspended black particles and fluid analysis revealed high aspergillus titers. Microbiological cultures grew aspergillus fumigatus.. The patient refused antifungal treatment with voriconazole and left against medical advice. Follow up revealed the patient expired two weeks later. DISCUSSION: The initial presentation of invasive aspergillosis, as in this patient, can be subtle and presents diagnostic challenges. Definitive identification requires culture of Aspergillus species from a normally sterile site along with histopathologic demonstration of hyphal tissue invasion. The diagnostic approach in patients with suspicious findings initially involves non-invasive modalities, such as fungal biomarkers, imaging studies, and fungal cultures followed by invasive procedures, such as bronchoscopy and biopsy in select cases [2,3] CONCLUSIONS: Despite advances in antiretroviral treatment, which have dramatically prolonged the survival of these patients, suspicion for aspergillosis in immunocompromised patients presenting with non-specific pulmonary symptoms should remain high, especially considering the risk of high mortality [3]. Clinicians should be alert to the possibility of invasive fungal infections in such high risk patients and be able to initiate early antifungal therapy for favourable outcomes. Reference #1: Denning D.W. - Invasive aspergillosis . Clin. infect. Dis., 26. 781-805, 1998 Reference #2: Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Patterson TF, Thompson GR 3rd, Denning DW, Fishman JA, Hadley S et al . Clin Infect Dis. 2016;63(4): e1. Epub 2016 Jun 29 Reference #3: Pulmonary aspergillosis and invasive disease in AIDS: Review of 342 cases Mylonakis E, Barlam TF, Flanigan T, Rich JD Chest. 1998;114(1):251. DISCLOSURES: No relevant relationships by Kamal Albright, source=Admin input No relevant relationships by Gregory Hoge, source=Web Response No relevant relationships by Sujan Jamarkattel, source=Web Response No relevant relationships by Ravi Manglani, source=Web Response

A Case of Invasive Pulmonary Aspergillosis with AIDS Occurring Immediately after Initiating Antiretroviral Therapy

A Case of Invasive Pulmonary Aspergillosis with AIDS Occurring Immediately after Initiating Antiretroviral Therapy

Événements infectieux survenus au cours des maladies auto-immunes traitées par rituximab : à partir d’une étude rétrospective de 93 cas

ObjectiveDescribe the occurring infections in patients treated with rituximab for an autoimmune disease. MethodsRetrospective and monocentric study of 93 adult patients treated with rituximab for autoimmune indications over a nine years period. ResultsThirty-eight patients suffered from a total of 95 infections. Out of them, 18 patients (19 %) had had at least an infectious episode triggering a hospital admission and/or intravenous treatment. The infections occurred mainly during the first year of the treatment (65 %) and if the courses are repeated (P=0.04). They were mainly pulmonary infections. Severe infections, recorded in 79 % of the cases, were mostly of bacterial origin (43 %) and viral (23 %). Two cases of pneumocystis pneumonia and one case of invasive pulmonary aspergillosis were also recorded. The notion of vaccination was present in less than half of the cases, and 39 % of the patients were already receiving a prophylactic treatment against pneumocystis pneumonia. Patients over the age of 65 years (40 %) had developed less infections (P<0.05). Eight of the initial 93 patients died, half of them because of infectious complications. ConclusionInfectious complications are frequent, become early and are potentially severe. Imputability to rituximab is not certain. However, this could lead to better codify rituximab prescriptions and take adapted and associated measures in order to facilitate infection prevention and, if an infection does occur, to treat it at the earliest stage possible. The age doesn’t seem to be a risk factor.

Aspergillus nidulans: A Rare Cause of Invasive Pulmonary Aspergillosis Resulting in Diffuse Alveolar Hemorrhage

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Invasive Pulmonary Aspergillosis (IPA) is an important source of morbidity and mortality in patients who are immunosuppressed. In the majority of cases, A. fumigatus is the causative species. We present a case of non-fumigatus IPA in patient on immunosuppressive therapy for a history of solid organ transplant. CASE PRESENTATION: Our patient is a 25 year old African American female with a history of cirrhosis secondary to autoimmune hepatitis for which she received a liver transplant in 2012 and had been maintained on immunosuppressive therapy with mycophenolate, prednisone, and tacrolimus. She initially presented to an outside hospital with complaints of fever, cough, and dyspnea. Two weeks prior to that she had been diagnosed with acute on chronic rejection, recurrent cirrhosis, and her prednisone dose was increased. She rapidly decompensated and required intubation. She was then transferred to our institution. Upon arrival copious blood was aspirated from the ET tube. Bronchoscopy revealed a white exudate with intermixed hemorrhage. Lavage culture was positive for A. nidulans. Serum (1-3)-Beta-D-Glucan and BAL/Serum aspergillus antigen ratio were markedly elevated. Rheumatologic workup included a skin biopsy of a rash that developed which was consistent with lupus. She was maintained on antibiotics, antifungals, and immunosuppressives and eventually was discharged to rehab. DISCUSSION: IPA mortality is highest amongst those who have had stem cell transplants or liver transplants. A. fumigatus is the most common causative agent and has been documented to occur in up to 90% of isolates. A. nidulans primarily affects patients with G6PD deficiency. In that population, hyphal angioinvasion is not seen. To our knowledge, only 1 other case of diffuse alveolar hemorrhage has been reported as caused by A. nidulans. Many factors contributed to her respiratory failure from DAH including underlying coagulopathy from cirrhosis, a new diagnosis of lupus, and pre-disposition to IPA from immunosuppression. A. nidulans has occurred more frequently in patients on anti-fungal prophylaxis which may suggest the existence of higher levels of resistance. Increased usage of anti-fungals as prophylaxis, as well as, increasing numbers of stem cell and solid organ transplants may lead to an increased number of cases of IPA and a change in the spectrum of pathology and species encountered. CONCLUSIONS: Atypical aspergillus species are uncommon but are a potential source of significant morbidity and mortality. Increased use of prophylactic anti-fungals may lead to increased resistance in the future. Reference #1: Liu, X., et al. (2011). Invasive fungal infections in liver transplantation. Int J Infect Dis 15(5):e298-304. Reference #2: Henriet S. et al. (2012). Aspergillus nidulans and Chronic Granulomatous Disease: A Unique Host-Pathogen Interaction. J Infect Dis. 206(7):1128-1137. Reference #3: Dimopoulos, G., et al. (2012). Invasive aspergillosis in the intensive care unit. Ann N Y Acad Sci 1272:31-39. DISCLOSURE: The following authors have nothing to disclose: Peter Rattner, Anne Sutherland No Product/Research Disclosure Information