Covid-19 Pneumonia and Invasive Pulmonary Aspergillosis

Introduction: Invasive pulmonary aspergillosis (IPA) is a rare, severe fungal infection with a poor prognosis and high mortality rate. IPA is mainly noted in patients with immunosuppressed status, hematological malignancies and stem cell transplants. Diagnosis is challenging and requires a high index of suspicion. Current literature supports treating patients with severe covid-19 pneumonia with high dose dexamethasone therapy for a prolonged period of time which may cause significant immune suppression. Here, we present a case of a patient with covid-19 pneumonia who developed IPA after dexamethasone and tocilizumab therapy. Case report: Patient is a 75-year-old male who was admitted to the medical ICU with severe hypoxemic respiratory failure secondary to covid-19 pneumonia requiring mechanical ventilation immediately on presentation to the emergency room. The patient had a past history of cavitary lung disease secondary to tuberculosis in 2018 and had completed treatment with 4-drug therapy. During this hospitalization, three sputum samples were negative for acid fast bacillus. He was started on dexamethasone therapy of 6mg daily for 10 days and received a single dose of tocilizumab. The patient initially improved but started to worsen again on the ninth day requiring increased ventilatory support and pronation therapy. His sputum culture grew Aspergillus FLavus. CT chest showed increased parenchymal infiltrates around prior cavitary lung disease. Serum aspergillus galactomannan antigen returned positive. Patient was started on intravenous Voriconazole. After initial improvement, the patient developed hemoptysis and worsening oxygenation. As per the family's wishes, patient was transitioned to comfort care and he passed away after compassionate extubation. Discussion:Treatment of COVID-19 pneumonia with high dose dexamethasone therapy may inadvertently cause an immunosuppressed state. These immunosuppressive effects may be further compounded by concurrent use of tocilizumab. Relative immunosuppression combined with possible epithelial damage due to viral infection may be a mechanism for development of IPA. A case series from France reported possible IPA in 9 of 27 (33.3%) ICU patients with COVID-19 with an expectedly high observed mortality rate. Conclusion: Clinicians should carry a high index of suspicion and pursue early investigations for other infections in COVID-19 patients who are not recovering or have worsened after initial improvement. Careful use of steroids in patients with prior structural lung disease is also warranted as they may be at high risk of developing IPA due to pre-existing aspergillus colonization.