SHM Converge Scientific Abstract ePoster Gallery-Bleeding Mycetoma: Case of Invasive Aspergillus in a Post-Covid Patient

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This case describes a 40-year-old Hispanic man with uncontrolled insulin-dependent type 2 diabetes and tobacco use who developed invasive pulmonary aspergillosis after recent severe COVID-19 pneumonia. He had been hospitalized three weeks earlier for DKA and COVID-19 requiring ventilatory support, steroids, and monoclonal antibody therapy.<br /><br />He returned with cough, shortness of breath, and fever. Workup showed marked leukocytosis, anemia, thrombocytosis, hyponatremia, and elevated inflammatory markers. Imaging demonstrated lingular consolidation with post-obstructive atelectasis and a left upper lobe tree-in-bud pattern. Bronchoscopy revealed polypoid, mucinous-appearing masses adherent to the bronchial wall. Histology showed septate hyphae with acute-angle branching forming a mycetoma, consistent with aspergilloma, with necrotizing pneumonia. HIV and QuantiFERON were negative, and Fungitell was positive. He was treated with voriconazole for six weeks and Augmentin for presumed bacterial pneumonia and initially discharged.<br /><br />One week later, he was readmitted with worsening respiratory and gastrointestinal symptoms. He was treated for presumed bacterial pneumonia, continued on voriconazole, and also found to have C. difficile infection. Despite antibiotics, antifungal therapy, and transfusions, he remained febrile, leukocytotic, and progressively anemic. On hospital day 7, he suffered sudden massive pulmonary hemorrhage from rupture of the mycetoma, leading to cardiac arrest and death.<br /><br />The report highlights the increasing recognition of COVID-19-associated pulmonary aspergillosis, including in patients without classic severe immunocompromise. It emphasizes that invasive aspergillosis can progress rapidly and be fatal even with guideline-directed therapy, raising concern for antifungal resistance and suggesting that aggressive interventions such as pulmonary resection may be needed in refractory cases.

Asset Subtitle

Sagar C. Patel

Meta Tag

Author List Joanne Zhu, Louis Lovett, Sagar C. Patel, Sara Acree

Category Clinical Vignettes

Concept COVID-19-associated pulmonary aspergillosis

Concept Pulmonary Aspergillosis

Concept Aspergilloma

Concept Necrotizing Fungal Pneumonia

Concept Antifungal Therapy

Distinguished Non-Finalist

Presenter Organization Wellstar Kennestone Hospital - Internal Medicine Residency Program

Presenting Author Sagar C. Patel

Track Adult

Keywords

invasive pulmonary aspergillosis

COVID-19-associated pulmonary aspergillosis

type 2 diabetes

aspergilloma

mycetoma

voriconazole

necrotizing pneumonia

pulmonary hemorrhage

bronchoscopy

fungal infection

COVID-19-associated pulmonary aspergillosis

Pulmonary Aspergillosis

Aspergilloma

Necrotizing Fungal Pneumonia

Antifungal Therapy