Fatal Invasive Pulmonary Aspergillosis Associated with Coronavirus Disease 2019 (COVID 19) Infection

Aspergillus is a ubiquitous fungus that causes a variety of clinical syndromes in the lung. The type and severity of airway and parenchymal disease produced by Aspergillus are influenced by the patient's immunologic status and the presence of pre-existing lung disease. There is increasing concern that patients with coronavirus disease 2019 (COVID-19) might be at risk of developing invasive pulmonary aspergillosis co-infection particularly in the context of immunomodulatory monoclonal antibodies. We present a case report of pseudomembranous aspergillus tracheobronchitis complicated by COVID-19 pneumonia. A 59-year-old female with a medical history of drug-induced interstitial lung disease from methotrexate, rheumatoid arthritis, was admitted to the intensive care unit secondary to dyspnea and hypoxemic respiratory failure. She was diagnosed recently with COVID-19 pneumonia treated with remdesevir and high dose systemic corticosteroids for 14 days. one week after she is re-admitted with shortness of breath requiring high flow nasal cannula. she had a temperature of 38.2°, blood pressure of 110/80 mmHg, heart rate of 90 bpm, and respiratory rate of 30 breaths/min. Chest auscultation was significant for diffuse bilateral inspiratory coarse crackles. She was started on broad-spectrum antibiotics with vancomycin and meropenem. RT PCR COVID test remains positive since the last admission and Anti-SARS-CoV-2 IgG Antibodies are negative. Arterial blood gas values were pH 7.41, PaCO2 63 mmHg, PaO2 60 mmHg, and SaO2 91%. The complete blood count showed hemoglobin of 10.1 g/L and 16,800 leucocytes, with no growth in blood cultures. Initial CT chest reveals bilateral diffuse ground-glass opacities consistent with COVID pneumonia. Subsequently, she was intubated and mechanically ventilated for worsening respiratory failure, empiric micafungin was started. A bronchoscopy demonstrated extensive whitish exudative membranes covering the trachea and both mainstem bronchi. The endobronchial biopsy specimens and bronchial washing fluid revealed Aspergillus fumigatus. Serum Galactomannan and fungitel came back positive. Micafungin was changed to isavuconazole, two days later the patient developed refractory septic shock. Despite using isavuconazole and supportive care, acute deterioration followed with refractory hypoxemia and oliguria, resulting in a fatal cardiac arrest on the sixth day of the intensive care unit stay. Aspergillus tracheobronchitis is an unusual manifestation of IPA accounts for <10% of cases. diagnosis of this condition is extremely difficult and hence is delayed given its relatively nonspecific presentation and the lack of specific radiographic findings. This case illustrates a need for careful screening for opportunistic infections in patients treated with high-dose systemic steroids, immunomodulators with underlying COVID pneumonia.