A Role for Empiric Aspergillus Coverage in Immunosuppressed Patients with Severe Influenza Pneumonia

Author:

U. Shaikh1, L. Cordova1, L. Concepcion1, P. Solari2, A. Danyalian1

Author address:

1Internal Medicine, Aventura Hospital Medical Center, Aventura, FL, United States, 2Infectious Disease, Aventura Hospital Medical Center, Aventura, FL, United States.

Full conference title:

American Thoracic Society Conference 2019

Date: 2 March 2020

Abstract:

Influenza presents a unique challenge in immunosuppressed patients. These patients usually present atypically and deteriorate quickly as they are at increased risk for superinfections. Significant evidence suggests that influenza is an independent risk factor for invasive pulmonary aspergillosis. There have been no trials to ascertain whether or not empiric antifungal therapy would be appropriate given the high risk of mortality. We present a case of ARDS precipitated by severe influenza pneumonia that eventually demonstrated biological markers consistent with probable invasive bronchopneumonic aspergillosis.
A 49-year-old female with medical history of rheumatoid arthritis and lupus on chronic immunosuppressive therapy presented to the hospital for generalized weakness and fall. Imaging revealed avascular necrosis of the right hip joint. At night, the rapid response team was activated for respiratory distress and hypoxemia. Extensive workup revealed rapid antigen influenza A positive, elevated A-a gradient and diffuse heterogeneous bilateral lung infiltrates. Patient was started on broad spectrum antibiotics, antivirals and steroids. Concern for pneumocystis jirovecii pneumonia necessitated the need to add TMP-SMX. A diagnostic bronchoscopy and bronchoalveolar lavage (BAL) were performed and sent for microbiological studies. Patient went on to develop severe ARDS refractory to paralytics, proning and optimal ventilator parameters. Patient expired with persistent hyperthermia on day 6 before cannulation for ECMO. The viral cultures from the BAL grew influenza A. Post-mortem, there was a high level of suspicion for invasive bronchopneumonic aspergillosis due to significantly elevated galactomannan in the BAL and confirmatory cultures are in process.
Superinfection with aspergillosis is an under recognized but well established phenomena in the context of severe influenza pneumonia. Diagnosing aspergillosis is a fundamentally difficult enterprise as the fungus is slow growing on culture. Clinicians need a high index of suspicion and may need to rely on galactomannan levels as empiric treatment may be needed due to quick clinical deterioration. In the absence of a well designed randomized control trial specifically studying the roll empiric antifungal therapy clinicians may need to resort to galactomannan levels from a BAL to initiate antifungal therapy until slow growing cultures come back. In the midst of the influenza season it is imperative to consider superinfection with invasive aspergillosis in immunosuppressed patients.

Abstract Number: A6600 / P49

Link to conference website:

Link Conference abstract: 

ATS 2019

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