LIVING WITH IT WORKING WITH IT TREATING IT
Introduction :Aspergillus pneumonia usually occurs in the immunocompromised individual. Major risk factors include prolonged neutropenia, chronic administration of corticosteroids, insertion of prosthetic devices, and tissue damage from prior infection or trauma. Usually pulmonary aspergillus manifests on imaging as single or multiple nodules with or without cavitation. We present a case of an individual with questionable immunocompetence, a precedent influenza A infection with suspicious Computed Tomography (CT) chest findings for an atypical infection such aspergillus diagnosed with methicillin susceptiblestaphylococcus aureus (MSSA) bacteremia.Case Presentation :A34 year old male with no past medical history presents to the Emergency Department with fevers, chills, and shortness of breath for the past 5 days. The patient also tested positive for influenza A at urgent care prior to presentation. Patient continued to have a worsening oxygen requirement titrating up to a Bi-level Positive Airway Pressure (BiPAP), Imaging revealing patchy airspace disease right lung base, elevated lactate, bandemia 41% ; therefore, admitted to the Intensive Care Unit (ICU) for acute hypoxic respiratory failure secondary to sepsis from community acquired pneumonia. CT Angiography of chest ruled out PE however significant for extensive bilateral mucus plugging with nodular component and atelectasis/infiltrates suspicious for an atypical infection along with mediastinal and bilateral hilar adenopathy. Infectious work up including blood culture grew MSSA and sputum culture isolated Aspergilusfumigatus species. ICU course complicated by diabetic ketoacidosis at which time he was newly diagnosed with diabetes mellitus. Patient was treated with broad spectrum antibiotics initially, infectious disease consulted and then continued with ceftriaxone 2 gram daily. Clinically improved, however discharged with supplemental oxygen and to return to the hospital daily for outpatient antibiotic therapy (OPAT). Discussion :This patient presumed immunocompetent presented with severe sepsis secondary to community acquired pneumonia. Outpatient he was diagnosed with influenza A and then newly diagnosed uncontrolled diabetic, which questions the immunocompetent status. Along with the severity of his illness, CT Lung revealing patchy nodularity and with sputum culture results, aspergillus could potentially be a causative agent in his septic picture. Argument against this would be that the patient was improving on ceftriaxone therapy for MSSA bacteremia along with not receiving antifungals. Risk factors for patients regardless of immunocompetent status include a preceding influenza A infection. The mortality rate drastically increases in invasive aspergillus infection if diagnosis and treatment is delayed therefore it is important, especially in immunocompromised host to maintain in the differential diagnosis.
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