Fatal Pulmonary Aspergillosis Complicating Influenza A Infection in a 58-Year-Old Woman

Author:

D. Mann, M. Assaad

Author address:

Summa Health Sytem, Akron, OH, United States.

Full conference title:

American Thoracic Society International Conference 2020

Date: 21 June 2020

Abstract:

Introduction. Invasive pulmonary aspergillosis (IPA) is usually seen in immunocompromised patients. However, IPA has occasionally been reported in immunocompetent patients who are critically ill, especially those with influenza pneumonia. Risk factors include chronic obstructive pulmonary disease (COPD), alcohol abuse, cirrhosis, diabetes mellitus, and use of corticosteroids. Aspergillus species grown from respiratory cultures are often regarded as only colonization or contamination. However, in critically ill patients, especially those with underlying influenza pneumonia, Aspergillus should be considered pathogenic, and antifungal therapy effective against Aspergillus species should be initiated immediately.

Case Presentation. A 58-year old woman with a past medical history of COPD, tobacco abuse, coronary artery disease, hypertension, type 1 diabetes mellitus, and prior alcohol abuse presented to the emergency department complaining of shortness of breath, nausea, and emesis. Additional symptoms included dry cough, pleuritic chest pain, fever, and chills. On the day of admission, Influenza A virus was detected by BioFire® FilmArray® Respiratory PCR Assay. Chest x-ray showed bilateral pulmonary infiltrates. She was treated with oseltamivir, ceftriaxone, and azithromycin. She developed worsening hypoxia and fever, and antibiotics were changed to vancomycin and piperacillin/tazobactam. The patient continued to deteriorate requiring intubation and mechanical ventilation for acute respiratory failure. Cultures from tracheal aspirate revealed methicillin-resistant Staphylococcus aureus (MRSA) and Aspergillus fumigatus. The patient’s renal function declined, and antimicrobial therapy was changed to parenteral Linezolid/Meropenem/Fluconazole. Bronchoscopy was performed and revealed diffuse bilateral acute tracheobronchitis with white patchy mucosal lesions and thick, bloody, serosanguineous secretions. Cultures from bronchoscopy again grew MRSA and Aspergillus fumigatus. Telavancin was added for synergistic effect against MRSA, and antifungal therapy was changed to Voriconazole plus Anidulafungin. Repeat imaging of the chest showed extensive multifocal, cavitary infiltrates and bronchiectasis with evidence of rapid lung destruction. Despite 2-drug anti-MRSA and 2-drug anti-Aspergillus therapy, the patient’s condition continued to decline and was goals were changed to comfort care; patient expired 16 days after admission.

Discussion. Influenza pneumonia predisposes immunocompetent patients to Aspergillus infection through multiple proposed mechanisms. Viral-induced damage to airway epithelium and impaired mucociliary clearance likely play a major role. Interestingly, influenza infection may induce lymphopenia, specifically apoptosis of T-lymphocytes. Although our patient was HIV-negative and was not neutropenic, her absolute CD4 T-cell count was significantly suppressed at 167 cells/µL. The use of multiple antibiotics for treatment of bacterial complications of influenza, as in our patient, may also promote colonization and subsequent infection with Aspergillus species.

Abstract Number: P74

Link to conference website:

Link Conference abstract: 

ATS 2020

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