LAUSR

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus associated pulmonary aspergillosis (CAPA) appears to be emerging on a global scale. Studies have consistently indicated that CAPA is associated with significantly higher mortality rates, when compared to patients with COVID-19 alone [1]. Unfortunately, definitive guidelines regarding the surveillance, diagnosis, & treatment of CAPA are currently lacking. CASE PRESENTATION: A 59 year old male with hypertension & diabetes presented with dyspnea & cough. On arrival, he was initially afebrile, though hypoxic & tachycardic. He tested positive for COVID-19 & influenza B on admission. Dexamethasone & remdesivir were initiated, along with oseltamivir & empiric antibiotics. CT of the chest was notable for bilateral ground glass opacities. On hospital day 11, he developed respiratory failure on BiPAP therapy, prompting intubation & ICU transfer. He subsequently succumbed to septic shock requiring hemodynamic support. Given concern for bacterial superinfection, antibiotic therapies were escalated. Despite the initial defervescence, he continued to have persistent febrile recrudescence. Blood & sputum cultures remained negative. He ultimately required tracheostomy and PEG tube placement. On day 38, his lower respiratory culture revealed growth of Aspergillus terreus. Voriconazole was initiated. On day 43, his fever returned again. Repeat CT of the chest revealed progressive fibrosis, with a cavitation in the right lower lung. He remained ventilator dependent, given his persistently high FiO2 requirements. On day 52, he became markedly hypoxemic with copious mucoid secretions, prompting emergent bronchoscopy. Despite clearance, he eventually became bradycardic & developed PEA arrest. The patient ultimately expired. DISCUSSION: CAPA remains a diagnostic challenge, fraught by logistical burdens & a variety of crudely defined criteria. Cases may currently be underreported, undertreated, or clinically overlooked. Obscure species such as A. terreus are of particular concern, given the proposed lethality of this strain & it's widely reported resistance to amphotericin B [3]. Unfortunately, guidelines for the surveillance of superinfections are currently insufficient. This is troublesome, considering the well documented risk of invasive pulmonary aspergillosis with the use of immunosuppressive agents, such as tocilizumab & corticosteroids [2]. Co-infection with influenza may augment this risk further. CONCLUSIONS: CAPA presents clinicians with a multitude of clinical uncertainties, which necessitate further analysis & investigation. Given the heightened risk of mortality, we propose a lower threshold for the suspicion, diagnosis & treatment of CAPA in patients with refractory respiratory distress, and/or febrile recrudescence despite the appropriate therapies. Surveillance should be particularly stringent, in those treated with immunosuppressive agents, or concomitantly diagnosed with influenza. REFERENCE #1: Apostolopoulou A, Esquer Garrigos Z, et al. Invasive Pulmonary Aspergillosis in Patients with SARS-CoV-2 Infection: A Systematic Review of the Literature. Diagnostics. 2020;10(10):807. REFERENCE #2: Koehler, P., Bassetti, M, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. The Lancet. Infectious diseases. 2020, Dec 20 REFERENCE #3: Steinbach, W, Benjamin, D, et al. Infections Due to Aspergillus terreus: A Multicenter Retrospective Analysis of 83 Cases, Clinical Infectious Diseases, Volume 39, Issue 2, 15 July 2004, Pages 192–198 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Sunil Bali, source=Web Response No relevant relationships by Christopher Siriphand, source=Web Response No relevant relationships by Christopher Wood, source=Web Response