The new onset of wheezing in an immunocompromised can herald serious endobronchial pathology.
We report a case of a 39 year old female with human immunodeficiency virus (HIV) well controlled on highly active antiretroviral therapy (CD4 596 and viral load < 50 copies/mL) and no prior pulmonary disease who was admitted to the intensive care unit with fever of unknown origin, lactic acidosis and thrombotic thrombocytopenic purpura. She was intubated, started on broad spectrum antibiotics, placed on continuous venous-venous filtration, plasmapheresed and given methylprednisolone 60mg IV Q6h. A bone marrow biopsy revealed B cell lymphoma. She was given vincristine, prednisone and procarbazine (CHOP) chemotherapy and became neutropenic. On the third day after CHOP, she remained febrile and was empirically started on liposomal amphotericin. On the fifth day, she developed diffuse bilateral wheezing and elevated peak pressures unresponsive to albuterol nebulizers or diuresis. Her chest X-ray showed new right upper and lower lobe collapse (Figure 1). A bronchoscopy revealed plaque-like growths coating the airways diffusely (Figure 2at the level of the carina and figure 3 of the right bronchus intermedius) and obstructing the right upper lobe bronchus (Figure 4). Bronchial brushings and biopsies were positive for septate hyphae consistent with Aspergillus. The patient was switched to voriconazole, caspofungin and aerosolized amphotericin but her condition continued to deteriorate with hypercapnia and hypotension. Care was withdrawn.DISCUSSION: Tracheobronchitis is an uncommon manifestation of Aspergillus with infection limited entirely or predominantly to the tracheobronchial tree. The patient population at risk for this form of Aspergillus includes primarily patients with HIV, neutropenia and lung transplant recipients. Early in the course of infection, it can go undiagnosed as it often occurs in the setting of a normal chest X-ray. Clinical manifestations include wheezing, cough, hypoxia and hemoptysis. Diagnosis is established by bronchoscopy with biopsy or brushings. The treatment includes systemic amphotericin B. There have been some case reports of aerosolized amphotericin B with variable clinical response. The outcome is poor. Patients can progress to transmural necrosis of the airways, tracheal perforation or invasive pulmonary Aspergillosis.
In immunocompromised patients with respiratory failure, the differential diagnosis of new onset wheezing not responsive to conventional treatments should include endobronchial fungal infections and should prompt early investigation by bronchoscopy.
C.A. Reichner, None.