Chest Infections |

A Case of Coinfection With Legionella and Aspergillus: There Is More to What Meets the Eye FREE TO VIEW

Hammad Arshad, MD; Adrija Mamidipalli, MD; Rajashekar Adurty, MD; Marvin Balaan, MD
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Allegheny General Hospital, Pittsburgh, PA

Chest. 2014;146(4_MeetingAbstracts):130A. doi:10.1378/chest.1994451
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SESSION TITLE: Infectious Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Coinfections caused by legionella and aspergillus fumigatus remain exceptional in patient on long term steroids.

CASE PRESENTATION: A 74-year-old female on chronic steroids for temporal arteritis,recent pulmonary embolism and history of pneumonia presented to our institution from a nursing home for possible sepsis.After obtaining cultures,patient was started on broad-spectrum antibiotics for a possible recurrent pneumonia.Laboratory data was pertinent for leukocytosis,hematuria and a positive urine legionella antigen.A chest CT scan showed emphysematous changes and a right upper lobe cavity with surrounding infiltrate.The cavitary lesion was persistent from a previous admission at an outside hospital where it was thought to be due to pulmonary infarction.Due to clinical deterioration despite antibiotic coverage for Legionella with Levofloxacin and development of hypoxic respiratory failure,bronchoscopy was performed for diagnostic purposes in this immune compromised patient.A bronchoalveolar lavage fluid culture was positive for the yeast Aspergillus fumigatus and the biopsy report confirmed Invasive Pulmonary Aspergillosis with the presence of the organism and acute inflammation.Voriconazole was subsequently added to levofloxacin resulting in clinical improvement.

DISCUSSION: Legionella and Aspergillus have a lot in common than what meets the common eye. They both have a predisposition for natural reservoirs and affect immune compromised individuals. They have been associated in the past with pulmonary embolism, with Aspergillus being isolated from cavitary pulmonary infarction. Both can cause cavitation in immune suppressed patients and have been misdiagnosed, and an associated higher mortality. We now report a unique case of co infection with Legionella and Aspergillus that occurred in a patient with upper lobe cavitary infarction

CONCLUSIONS: The case illustrates the fact that despite a working diagnosis,an aggressive invasive approach may have to be undertaken to identify a coexistent process.It highlights the importance of analyzing respiratory cavitary lesions to document the infection and initiate appropriate treatment.Concomitant infection with both bacterial and opportunistic organism in an immune compromised host must be considered and dealt with aggressively.

Reference #1: Pulmonary aspergillosis: a clinical review;M Kausha et al.Eur Respir Rev 2011;20:121,156-174

Reference #2: Legionella and Legionnaires Disease;25 years of investigation;S Fields,F Benson; Clinical Microbiology review July 2002; 506-526

DISCLOSURE: The following authors have nothing to disclose: Hammad Arshad, Adrija Mamidipalli, Rajashekar Adurty, Marvin Balaan

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