Objectives: To present the case of immunocompromised patient who was diagnosed with рulmonary aspergillosis in a short period of time after established diagnosis of autoimmune hepatitis.
Methods: We examined 69-year-old man who had spitting blood, cough, signs of abscess pneumonia in x-ray examination after 5 weeks of immunosuppressive therapy with decreasing dose of glucocorticoids that was prescribed after the second episode of bilirubinemia when diagnosis of autoimmune hepatitis was established after scrutinizing diagnostic search. Sputum was analyzed with standard and fluorescent microscopy with white calcofluor and cultural method. Standard methods were applied to exclude tuberculosis and aspergillosis. Galactomannan (GM) detection was performed with immunoenzymatic assays XEMA GaIMAg EIA kit (Russia). Positive level of GM accounted for ≥0.59 OD (optical density).
Results: Cultural methods revealed the presence in sputum E.coli (107 ) and A.flavus (105 ) (pic.1). GM level initially was positive in blood (0.73 OD). Antifungal voricоnazol therapy was started immediately. Оne week after starting treatment the second cultural testing of nose crust showed A.flavus (104 ) (pic.2);
GM was negative in blood and urine (0.41 OD and 0.14 OD respectively), and positive in bronchoalveolar lavage fluide (BALF) accounting for 2.34 OD. Futher cultural testing did not detect A.flavus. GM level was positive only in BALF. Spiral computed tomography revealed several aspergillomas, the size of the largest one was 70x50 mm. The patient did not have leukopenia at any time from the first episode of hepatitis, however slight lymphopenia was observed. Оne month after diagnosis of pulmonary aspergillosis pneumothorax and secondary bacterial complications occurred. Despite this the patient has demonstrated positive clinical effect continuing antifungal and antibiotic therapy (in accordance with the sensitivity of microorganisms) with accompanying therapy by the third month since the diagnosis of aspergilllosis. The remission of autoimmune hepatitis has been observed.
Conclusion. It should be taken into consideration that immunocompromised patients even without leukopenia/agranulocytosis and short period of immunosuppressive therapy are at risk of development fungal infection. GM testing demonstrates its usefulness for early diagnosis Aspergillus spp. A comprehensive approach to diagnosis and alertness of doctors for fungal infection can improve the detection of cases of aspergillosis.
Full conference title:
- TIMM (2019)