Immunosuppression and persistent sars-cov-2 infection associated with invasive aspergillosis complicated with fungal empyema and bronchopleural fistula: a case report

SESSION TITLE: Chest Infections Case Report Posters 11 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: People who are immunocompromised or have preexisting lung disease are at a higher risk of developing fungal infections, including Aspergillosis. Here we discuss a case of invasive Aspergillosis complicated by fungal empyema with bronchopleural fistula formation in an individual with chronic immunosuppression and persistent SARS-CoV-2 infection. CASE PRESENTATION: A 64-year-old male with a medical history of chronic persistent SARS-CoV-2 infection, paraneoplastic pemphigus on long-term prednisone, cyclosporine, and prophylactic Bactrim, follicular B cell lymphoma previously on Obinutuzumab presented to the hospital with dyspnea and chest pain. About a month prior, he had a similar admission, receiving Remdesivir and compassionate use of Casirivimab-Imdevimab (REGN-COV2). Imaging during that admission was consistent with pulmonary infiltrates.During current admission, Chest X-ray showed a new cavitary lesion on the lung's left upper lobe, which was later confirmed with a chest CT scan (figure 1). Due to high suspicion of Aspergillosis, bronchoscopy with biopsy was performed along with the collection of sputum culture, serum galactomannan, and Beta-D glucan assay. All investigations pointed towards invasive Aspergillosis, with Aspergillus fumigatus (Table 1) being the cause. Consequently, he was started on isavuconazole as an alternative to voriconazole due to the underlying acute kidney injury. A few days into admission, he developed acute worsening dyspnea and was found to have left-sided pneumothorax (figure 2), for which a chest tube was inserted. The pneumothorax continued to progress in size, requiring additional chest tube insertion; He progressively desaturated, eventually requiring intubation with mechanical ventilation; and septic shock requiring vasopressors. Repeat CT scan post-intubation was consistent with persistent left basilar pneumothorax and pleural effusion, consistent with thick purulent material when drained. These findings suggested a formation of bronchopleural fistula, an extremely rare complication of invasive Aspergillosis. Anidulafungin was added to the existing isavuconazole regimen, and he was also started empirically on meropenem. Despite the treatment and supportive measures, he eventually succumbed to his illness. DISCUSSION: Invasive pulmonary Aspergillosis (IPA) is increasingly recognized in patients with SARS-CoV-2 infection, especially with severe pneumonia, ARDS, and steroid therapy. It must be considered a serious and potentially life-threatening complication. This, together with immunosuppression, as seen in our patient, places such individuals at higher risk for IPA. Recurrent pneumothorax may be a rare manifestation of aspergillus infection and is more often seen in individuals with chronic lung disease. Aspergillus empyema thoracis is even rarer and caused by rupture of an aspergilloma cavity or as a complication of a preexisting chronic empyema with high mortality requiring prompt treatment with antifungal and drainage. CONCLUSIONS: Early recognition and treatment of invasive pulmonary Aspergillosis are essential to mitigate the high morbidity and mortality in patients with immunosuppression and chronic persistent SARS-CoV-2 infection. REFERENCE #1: KAO, C. T., JU LEE, Y., & SALEM, A. (2021, October). SECONDARY SPONTANEOUS PNEUMOTHORAX FROM INVASIVE ASPERGILLUS. Chest, 160(4), A445. https://doi.org/10.1016/j.chest.2021.07.438 REFERENCE #2: Machado M, Valerio M, Álvarez-Uría A, Olmedo M, Veintimilla C, Padilla B, De la Villa S, Guinea J, Escribano P, Ruiz-Serrano MJ, Reigadas E, Alonso R, Guerrero JE, Hortal J, Bouza E, Muñoz P; COVID-19 Study Group. Invasive pulmonary aspergillosis in the COVID-19 era: An expected new entity. Mycoses. 2021 Feb;64(2):132-143. doi: 10.1111/myc.13213. Epub 2020 Nov 29. PMID: 33210776; PMCID: PMC7753705. REFERENCE #3: Kuehn BM. Aspergillosis Is Common Among COVID-19 Patients in the ICU. JAMA. 2021;326(16):1573. doi:10.1001/jama.2021.17973 DISCLOSURES: No relevant relationships by Ayah Alkhidir No relevant relationships by Mubashir Ayaz Ahmed No relevant relationships by Andranik Bedross No relevant relationships by Shayet Hossain Eshan No relevant relationships by Sami Hussein No relevant relationships by Sudha Misra No relevant relationships by Zahin Islam Rafa No relevant relationships by Hina Wazir