Clinical neglect of aspergillosis in pulmonary tuberculosis coinfection: a case report of avoidable mortality in a resourceconstrained setting

Background: Pulmonary aspergillosis (PA) is common among patients with tuberculosis (TB). With both infections presenting with similar clinical and radiologic features, diagnosis of PA is often made too late or missed completely due to lack of clinical suspicion and poor diagnostic laboratory  capacity for mycotic infections prevalent in our settings. We present a case of preventable mortality caused by delayed diagnosis and treatment of  PA in a patient with pulmonary TB (PTB). Case presentation: A 13-year-old female was diagnosed and treated for PTB, having received anti-TB regimen for 8 months in a mission hospital  from where she was referred due to worsening cough, chest pain and progressive breathlessness. The patient was re-assessed and investigated,  with GeneXpert detecting Mycobacterium tuberculosis, susceptible to rifampicin. Diagnosis of pulmonary tuberculosis complicated by right  pneumothorax was made indicating an emergency thoracotomy and chest tube insertion and continuation of the first line anti-TB regimen. At about  2 weeks into admission, patients had features of superimposed acute bacterial sepsis with fever becoming high grade, marked neutrophilia  with toxic granulation and elevated sepsis biomarker, and this necessitated empiric antibiotic treatment with parenteral meropenem and  vancomycin. However, the patient only had mild clinical improvement following which there was progressively worsening respiratory symptoms and  massive haemoptysis. Result of sputum fungal study was available on admission day 20 and revealed a growth of Aspergillus flavus. Treatment with  intravenous voriconazole was however commenced rather late when the fungal respiratory disease could no longer be remedied. The patient died  on admission day 23. Conclusion: Diagnosis of PA in patients with background TB is often made too late to guarantee timely and effective  antifungal treatment with negative consequences on patients’ outcomes. Improving clinical and laboratory capacities is essential to reducing  mortality from PA in healthcare facilities.