Chest Infections |

Invasive Pulmonary Aspergillosis in an Unusual Host FREE TO VIEW

Julie Zaidan, MD; Boutros Karam, MD; Marc Saad, MD; Ambreen Khalil, MD
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Staten Island University Hospital, Staten Island, NY

Chest. 2015;148(4_MeetingAbstracts):110A. doi:10.1378/chest.2250641
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SESSION TITLE: Chest Infections II: Student Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Invasive aspergillosis, known to occur in immunocompromised patients, is recently reported in immunocompetent hosts often leading to fatal outcome. We are reporting a case of invasive aspergillus pneumonia in a patient without known risk factors, who recovered after early recognition and adequate treatment.

CASE PRESENTATION: This is a 55 year old African-American male presenting with 2 weeks history of high grade fever and weakness, with no other symptoms. PMH was significant for non metastatic pancreatic cancer treated with whipple procedure 3 months ago and 6 cycles of Gemcitabine. Upon presentation, Temperature was 101.80F. Physical exam was unremarkable. Initial workup showed WBC 9 .76 TH/mm3 ( Granulocytes 62%) with 17 % monocytosis; chest X-Ray was normal. Despite broad spectrum antibiotics with cefepime and vancomycin, he remained febrile. All cultures and quantiferon were negative. On day 7, the patient developed mild shortness of breath and non productive cough, requiring 2L/min of oxygen. Physical exam revealed new fine bilateral crackles; chest x-ray showed bilateral patchy infiltrates; patchy bilateral air space consolidations were noted on CT-scan suggesting multifocal pneumonia. Patient had bronchoscopy retrieving cloudy colorless fluid, few wbc, negative stain and culture for fungal or bacterial organisms. Serum Galactomannan antigen was highly positive (Index value 1.38- cutoff of 0.5) suggesting invasive aspergillus pneumonia. The patient was started on mycafungin, became afebrile in 24 hours with significant improvement. There was complete resolution of the infection after 2 weeks of voriconazole therapy.

DISCUSSION: The diagnosis of Invasive aspergillosis is challenging and based on the host risk factors and mycological support: It is definite with a histopathological isolation; possible in a susceptible host with supportive imaging, and probable when combined with mycological evidence. Invasive aspergillosis commonly occurs in patients with prolonged neutropenia, allogeneic stem cell transplant, high dose and prolonged use of corticosteroids, treatment with T cell immunosuppressant, chronic lung disease and cancer, hematological malignancies. Medical imaging and serum galactomannan antigen currently constitute the basis of the screening approach, although not very specific.

CONCLUSIONS: Previously reported cases in immunocompetent hosts had fatal outcomes mainly attributed to the delayed diagnosis. We relied our diagnosis on the CT findings, the galactomannan test and the response to therapy. Early diagnosis and initiation of treatment are essential to best outcome.

Reference #1: Cornillet A et al. Comparison of epidemiological, clinical, and biological features of invasive aspergillosis in neutropenic and nonneutropenic patients: a 6-year survey. Clin Infect Dis. 2006;43(5):577-84.

Reference #2: Desoubeaux G, Bailly É, Chandenier J. Diagnosis of invasive pulmonary aspergillosis: updates and recommendations. Med Mal Infect. 2014;44(3):89-101.

DISCLOSURE: The following authors have nothing to disclose: Julie Zaidan, Boutros Karam, Marc Saad, Ambreen Khalil

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