ABSTRACT
INTRODUCTION: Tracheobronchial aspergillosis (TBA) can be a difficult diagnosis despite being seen in up to a third of critically ill patients with COVID-19 with a high mortality rate. We report a case of TBA found on bronchoscopy shortly after COVID-19 infection diagnosis. DESCRIPTION: A 49-year-old woman with diabetes presented with encephalopathy, nausea, and malaise and a 1-day history of COVID-19 infection. She was initially stable, on 2 liters of oxygen via nasal cannula. She had a WBC of 27,000, procalcitonin: 10.9 ng/ml along with diabetic ketoacidosis (DKA), hemoglobin A1C: 15.5%, and acute kidney injury. She was treated for DKA and started on Remdesivir and Dexamethasone for COVID-19 infection. DKA resolved within 24 hours, however, she became hypoxic, bradycardic and had a PEA arrest on second day. After resuscitation, her beta-glucan was 364 pg/ml and Micafungin was started. She then developed severe worsening compliance on the ventilator. CT scan of the chest was non-revealing. Bronchoscopy for concerns of airway obstruction showed diffuse black-green dense exudate in trachea and bilateral airways with acute inflammation, suggestive of aspergillosis, later confirmed on cultures. She was switched to Amphotericin B. Patient further declined and was transitioned to comfort care after 5 days. DISCUSSION: TBA mostly afflicts patients with neutropenia, leukemia, HIV, transplantation and >3 weeks steroid treatment. It is also described in ventilated patients with viral infections like influenza. COVID-19 patients are also found to be susceptible to developing TBA with reports of 19-33% of patients having aspergillus in their BAL with mortality rate up to 65%. The diagnosis is often elusive prompting redefining guidelines for diagnosis of TBA. Except for short course of steroids and uncontrolled diabetes, our case did not have any other risk factors for TBA. Her accelerated TBA course can be attributed to her COVID-19 and/or its treatment. The CT imaging and ventilator findings could have been explained by COVID-19 infection. The high peak pressures on the ventilator prompted further investigation by bronchoscopy that uncovered her aspergillus infection. Considering the high mortality rate of TBA, our case shows high level of suspicion and thorough workup is needed for its diagnosis.