IPA was first described in 1953. Due to
widespread use of chemotherapy and immunosuppressive agents, its incidence has increased
over the past two decades. Of all autopsies
performed between 1978 and 1992, the rate of
invasive mycoses increased from 0.4% to 3.1%, as
documented. IPA increased
from 17% to 60% of all mycoses found on autopsy
over the course of the study. The mortality rate of
IPA exceeds 50% in neutropenic patients and
reaches 90% in haematopoietic stem-cell transplantation (HSCT) recipients
1. D R K A M A L B H A R A T H I . S
P O S T G R A D U A T E
D E P A R T M E N T O F P U L M O N A R Y M E D I C I N E
S R I M A N A K U L A V I N A Y A G A R M E D I C A L C O L L E G E & H O S P I T A L
P U D U C H E R R Y
CLINICAL GRAND
ROUNDS
2. CASE REPORT
41 year old male, Chronic alcoholic
Came to our casualty with C/O epigastric pain for
past 5 days.
Not a known hypertensive, diabetic, asthma or TB
Initially admitted at surgical unit with clinical
suspicion of pancreatitis.
USG abdomen- pancreas with mild echogenic and
thin rim of peri-pancreatic fluid.
3. LABORATORY DATA
Hemoglobin 15.7gm/dl
Total Leukocyte
Count
22,700 cells/cm
Neutrophils 88%
Platelet count 3.48 lakhs/cm
Urea 21mg/dl
Creatinine 1.2mg/dl
Total bilirubin 1.0 mg/dl
Direct Bilirubin 0.2 mg/dl
SGOT 30 U/L
SGPT 44 U/L
Sr Albumin 2.9 g/dl
Sodium 135 mmol/L
Potassium 3.4 mmol/L
Chloride 101 mmol/L
Calcium 7.7 mg/dl
Serum lipase 45 U/L (N)
HIV Non reactive
HBsAg Non reactive
HCV Non reactive
Serum amylase 13 U/L (N)
5. CLINICAL HISTORY
Pulmonology opinion was obtained on the next day
of admission.
Patient also gave history of left sided chest pain
which increased on deep inspiration for past 5 days.
C/O of non-productive cough and dyspnoea for the
past 2 days.
6. PHYSICAL EXAM
On examination- conscious, alert and tachypnoic
using accessory muscles of respiration.
Vitals: PR- 112/min; BP- 136/90 mmHg; RR- 38
breath/min; SpO2- 94 %@room air
On palpation revealed intercostal tenderness over
left infra-axillary area.
Reduced vesicular breath sounds in the left side
infra-axillary and mammary area.
Patient was transferred to RICU for non invasive
ventilation.
8. THORACOCENTESIS
Screening USG thorax- gross
collection in left pleural space
with multiple internal echoes
suggestive of empyema.
Diagnostic tapping was done
showing pus which was sent
for gram stain, culture, AFB
and fungal smear.
ICD was inserted and drained
around 1700ml of frank pus.
9. PROVISIONAL DIAGNOSIS
Post ICD insertion, patient’s tachypnea got settled
down.
Patient was planned for CT thorax but postponed as
the patient was in Respiratory Failure.
With working diagnosis of left empyema/ sepsis/
impending ARDS, Patient was started on
clindamycin in addition to piperacillin+ tazobactam
and continued on NIV support.
10. REPORTS
Pleural fluid (Pus)
Gram stain: no evidence of bacteria
Culture: no growth
AFB: Smear negative for AFB
Fungal smear: few septate branching fungal elements seen.
CBNAAT: MTB not detected
Sputum
Gram stain: few gram +ve cocci in short chains
Culture: throat commensals
Fungal smear: few septate branching fungal elements seen.
Fungal culture: negative for fungus
CBNAAT: MTB not detected
11. WORK UP
Bedside bronchoscopy was
performed with NIV support
which showed brownish
mucopurulent secretions almost
in all segmental bronchus.
Transbronchial lung biopsy was
planned it was abandoned as the
patient couldn’t tolerate the
procedure.
BAL fungal smear and culture
was also sent.
12. CULTURE
Microbiologist was insisted and asked to review again on
the fungal smear and found few septate acute angled
branching fungal mycelium.
Fungal culture (Pus):Aspergillus species.
14. HOSPITAL COURSE
Started on Injection Voriconazole 6mg/kg on day 1
twice daily followed by 4mg/kg on subsequent days
with other supportive measures.
Patient was not showing any clinical response and
rapid worsening with hypoxemia.
Urine and blood culture and sensitivity : No growth
Serum IgM 91 mg/dl (N)
Serum IgG 1251 mg/dl (N)
Serum IgA 103 mg/dl (N)
Serum Procalcitonin 0.57 mcg/L
16. HOSPITAL COURSE
As there was clinical worsening and new rapidly
progressive infiltrates on right lung, liposomal
amphotercin B (4mg/kg) was added along with
voriconazole.
Suspecting secondary bacterial infection antibiotics
were escalated to Inj. Imipenam and Inj.
clindamycin.
Patient was planned for elective intubation, but
patient attenders were not willing and continued
with continous NIV support.
17. HOSPITAL COURSE
After starting liposomal amphotericin B, patient
showed partial clinical response so continued with
intermittent NIV.
Potassium infusion was given to correct hypokalemia
regularly.
Patient was shifted for CT thorax with oxygen
support.
19. WORK UP
CTVS opinion obtained and adviced for surgery and
planned for lobar resection but the patient was not
willing to undergo surgery.
20. WORK UP
Patient was not responding to voriconazole and no
major commercial laboratories are running fungal
culture sensitivity.
Patient was complaining of blurred vision and
headache for which ophthalmologist opinion was
obtained and suggested that it was because of
voriconazole induced transient visual disturbance.
So, voriconazole was stopped.
21. HOPITAL COURSE
Hence, Inj. Capsofungin was started along with
liposomal amphotericin B.
After 3 days of treatment with Capsofungin 50mg
and liposomal amphotericin combination, patient
had shown good clinical response.
Patient shifted to ward after a week.
22. FOLLOW UP
Patient symptomatically improved with significant
radiological resolution.
25. Take Home Message
Atypical presentation of epigastric pain which mimicked a
pancreatitis initially.
Empyema – though rare still it can be fungal !!!
Suspected to have mixed bacterial infection and treated and
later came out as pleuropulmonary aspergillosis.
As diagnostic yield of sputum shows low sensitivity, NIV
facilitated fibreoptic bronchoscopy was done which showed
positive culture.
BAL galactomannan assay aids in diagnosis with 90%
sensitivity and performed better compared to PCR and
serum galactomannan.
26. Take Home Message
Voriconazole is the preferred drug for first line therapy
for which patient has not shown any clinical response
hence combination therapy was considered.
Combination therapy has shown additive or synergistic
effects and in our case a good clinical as well as
radiological resolution was seen.
Invasive pulmonary apergillosis is more common in
immunocompromised patients, but our patient is
immunocompetent except the history of alcoholism.
As patient was not willing for elective intubation,
patient was continued with NIV support and weaned
off successfully with treatment.
Patient was on NPO, IV antibiotics and other conservative measures as advised by surgeon.
Heterogenous opacity involving left mid zone and lower zone suggestive of lobar pneumonia.
Chest x-ray done showing left homogenous opacity invoving whole hemithorax with contralateral mediastinal shift suggestive of massive pleural effusion.
Pus non foul smelling
Breath hold
immunofluorescence assay
patient was not responding and CXR showed opposite side heterogenous opacity involving whole right hemithorax.
CT thorax was done which showed the presence of multifocal consolidation and interlobular thickening with patchy areas of ground glass opacity. Thick walled cavitating nodule in the left lower lobe with residual left pleural collection post intercoastal drainage.
