COVID-19 breakthrough infection after four doses of the vaccines: a case report

The COVID-19 vaccines provide a high degree of protection against severe disease, hospitalisation, and death. However, no vaccine claimed 100% effectiveness and it is expected that a small proportion of vaccinated individuals may develop a breakthrough infection due to individual differences, virus variants and other factors. We conducted an epidemiological investigation and analysis of an imported case who had finished four doses of vaccination, and in order to provide a relevant reference for regular epidemic prevention and control in the post-pandemic era.

Risk factors for COVID-19 incidence and mortality in patients on maintenance hemodialysis

Patients on maintenance hemodialysis (MHD) are highly susceptible to SARS-CoV-2 and with high mortality rates due to Coronavirus disease 2019, mainly because of the older age in this group of patients, comorbidities, compromised immune status due to uremia, as well as inability to keep social isolation because of the necessity for regular physical presence in dialysis facility. Several retrospective studies of patients on MHD in Europe, America and Asia, show high susceptibility to SARS-CoV-2 in this group of patients with very high rates of critical course of the disease and high mortality rates, reaching more than 40% The aim of this retrospective observational study was to identify risk factors among patients on intermittent hemodialysis for infection with SARS-CoV-2 as well as predictors of severe COVID-19 and fatal outcome. Materials and methods. We analyzed 69 patients receiving intermittent dialysis in Aleksandrovska University Hospital - Hemodialysis Unit. 34 of them have been tested positive for SARS-CoV-2 in the period from September 2020 (when the first case of the disease was registered for our dialysis center) up to March 2022, and are compared with a control group of 35 dialysis-dependent patients without COVID-19. Data about comorbidities, main laboratory and radiologic findings, need of hospitalization and treatment in ICU, as well as data for conducted treatment, are collected from electronic medical records. To identify predictors of severe COVID and poor outcome we compared the group of survivors with the one of non-survivors. Results. There are no significant differences between patients on MHD with and without COVID-19 except higher frequency of COPD and hypoproteinemia in the positive group. Older age, female gender, history of smoking, lymphopenia with neutrophilia, treatment in ICU and need of mechanical ventilation, signs of malnutrition - hypoproteinemia and lower levels of serum creatinine, are risk factors for severe disease and fatal outcomes. Conclusions. The course of COVID infection in dialysis-dependent patients is severe and with high mortality rate, in line with other studies worldwide. Malnutrition is the main risk factor for COVID and also main predictor for poor outcomes.

Integrating deep learning algorithms for the lung segmentation and body-part-specific anatomical classification with Medical Imaging and Data Resource Center (MIDRC)

Medical Imaging and Data Resource Center (MIDRC) has been built to support AI-based research in response to the COVID-19 pandemic. One of the main goals of MIDRC is to make data collected in the repository ready for AI analysis. Due to data heterogeneity, there is a need to standardize data and make data-mining easier. Our study aims to stratify imaging data according to underlying anatomy using open-source image processing tools. The experiments were performed using Google Colaboratory on computed tomography (CT) imaging data available from the MIDRC. We adopted the existing open-source tools to process CT series (N=389) to define the image sub-volumes according to body part classification, and additionally identified series slices containing specific anatomic landmarks. Cases with automatically identified chest regions (N=369) were then processed to automatically segment the lungs. In order to assess the accuracy of segmentation, we performed outlier analysis using 3D shape radiomics features extracted from the left and right lungs. Standardized DICOM objects were created to store the resulting segmentations, regions, landmarks and radiomics features. We demonstrated that the MIDRC chest CT collections can be enriched using open-source analysis tools and that data available in MIDRC can be further used to evaluate the robustness of publicly available tools. © 2023 SPIE.

Informational inefficiency on bitcoin futures

This paper investigates the dynamics and drivers of informational inefficiency in the Bitcoin futures market. To quantify the adaptive pattern of informational inefficiency, we leverage two groups of statistics which measure long memory and fractal dimension to construct a global-local market inefficiency index. Our findings validate the adaptive market hypothesis, and the global and local inefficiency exhibits different patterns and contributions. Regarding the driving factors of the time-varying inefficiency, our results suggest that trading activity of retailers (hedgers) increases (decreases) informational inefficiency. Compared to hedgers and retailers, the role played by speculators is more likely to be affected by the COVID-19 crisis. Extremely bullish and bearish investor sentiment has more significant impact on the local inefficiency. Arbitrage potential, funding liquidity, and the pandemic exert impacts on the global and local inefficiency differently. No significant evidence is found for market liquidity and policy uncertainty related to cryptocurrency.

The danger of inappropriate use of personal protective equipment

The coronavirus pandemic is a global health emergency which has had widespread unforeseen mental health consequences. Those with borderline personality disorder are predisposed to poor coping strategies to manage such stress and require intense psychological input which was not widely available during the peak of the pandemic. It is likely that the coronavirus outbreak has had a significant impact on the mental stability of such patients aggravating deliberate self-harm behaviours. A 20-year old psychiatric in-patient with borderline personality disorder, held under Section III of the mental health act, presented to the adult plastic surgery team in Bristol with localised infection of her right forearm. Foreign bodies were easily palpable and imaging revealed linear metal objects. The patient reported that she had removed metal strips from her collection of face masks and inserted them into her forearm as an act of deliberate self-harm. The patient was taken to operating theatre for removal of these foreign bodies under general anaesthetic. After twenty-four hours of antibiotics she was discharged safely back to the psychiatric ward. Despite the epilogue of the COVID-19 pandemic facemasks are still mandatory within the hospital setting. Clinicians need to be aware of these unusual circumstances where a form of protective equipment was deconstructed to cause actual bodily harm. The purpose of this report is to promote awareness of this type of injury especially in those suffering from mental illness. The authors would suggest an alternative mask without any form of metal.

Oesophageal and oral ulcer tuberculous associated with human T-cell lymphotropic virus type 1 (HTLV-1) and SARS-CoV-2 infection

Oesophageal involvement due to tuberculosis (TB) and coinfection with HTLV-1 is rare and can be complicated by the presence of other infections that affect the mucosa of the upper respiratory tract, such as COVID-19. We present the case of a 27-year-old male patient, with 3 months of illness, weight loss, dysphagia, and ulcers in the oral cavity. Tomography showed oesophageal perforation and after oesophageal ulcer biopsy, TB was diagnosed, in addition to infection by HTLV-1 and severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The patient responded satisfactorily to antituberculous treatment and corticosteroids. Considering the association between rare extrapulmonary tuberculosis and other immunosuppressive pathologies, it is crucial to identify these pathologies in such patients.

Individual intensive nursing care plan for pseudomembranous colitis due to antibiotic treatment of COVID-19

In recent years, a number of complications have been observed as a result of uncontrolled antibiotic treatment. One of them is gastrointestinal dysbiosis. Not infrequently it is the cause of pseudomembranous colitis, a disease with a remarkably high associated mortality. It can be severe and requires serious medical care. This report presents a clinical case of a patient who developed the disease pseudomembranous colitis after antibiotic treatment for a Covid infection. The aim of the report is to define and present in a systematized manner the nursing care provided in the specific case. The daily analysis of the patient's condition allows to offer complex, adequate and individual nursing care, which, in addition to meeting her needs, also aims to alleviate her condition.

An actuarial model of the economic cost of the first year of a pandemic and the community mobility index

The COVID-19 pandemic significantly affected world economics. Thus, to anticipate the possibility of a future pandemic, it is crucial to find a proper way to simulate and estimate the cost of a pandemic, which is critical to the economy and welfare. This paper presents an actuarial Susceptible-Infected-Recovered and Death (SIR-D) multiple-state model that estimates the cost of a pandemic through the Cost-of-Illness (COI) analysis for both individual and regional levels. The model can be used to design financial products anticipating future pandemics. Formulas are constructed for two categories of COI, i.e., direct costs and productivity losses. The COIs are calculated annually and weekly throughout the year 2020. We also build and analyze multiple regression models that picture the relationships between community mobility and the amount of economic burden. We apply the model to studying the USA, India, Indonesia, Canada, Australia, and Taiwan. Indonesia, India, and the USA have the world-largest populations. In addition, Australia and Taiwan were known to apply strict border control, tracking, and quarantine in 2020. The models indicate moderate to high correlations between community mobility and economic burden during the first year of the COVID-19 pandemic. © 2023, ICIC International. All rights reserved.

Identifying Safety Subgroups at Risk: Assessing the Agreement Between Statistical Alerting and Patient Subgroup Risk: An International Journal of Medical Toxicology and Drug Experience

Introduction Identifying individual characteristics or underlying conditions linked to adverse drug reactions (ADRs) can help optimise the benefit-risk ratio for individuals. A systematic evaluation of statistical methods to identify subgroups potentially at risk using spontaneous ADR report datasets is lacking. Objectives In this study, we aimed to assess concordance between subgroup disproportionality scores and European Medicines Agency Pharmacovigilance Risk Assessment Committee (PRAC) discussions of potential subgroup risk. Methods The subgroup disproportionality method described by Sandberg et al., and variants, were applied to statistically screen for subgroups at potential increased risk of ADRs, using data from the US FDA Adverse Event Reporting System (FAERS) cumulative from 2004 to quarter 2 2021. The reference set used to assess concordance was manually extracted from PRAC minutes from 2015 to 2019. Mentions of subgroups presenting potential differentiated risk and overlapping with the Sandberg method were included. Results Twenty-seven PRAC subgroup examples representing 1719 subgroup drug-event combinations (DECs) in FAERS were included. Using the Sandberg methodology, 2 of the 27 could be detected (one for age and one for sex). No subgroup examples for pregnancy and underlying condition were detected. With a methodological variant, 14 of 27 examples could be detected. Conclusions We observed low concordance between subgroup disproportionality scores and PRAC discussions of potential subgroup risk. Subgroup analyses performed better for age and sex, while for covariates not well-captured in FAERS, such as underlying condition and pregnancy, additional data sources should be considered.

Systemic and Local Disease Manifestations Following COVID-19 Vaccination

Introduction/Objective COVID-19 vaccine-related lymphadenopathy, particularly in the ipsilateral axilla, is a relatively well-known side effect of mRNA vaccines with many reports in radiology, but less is known regarding histopathology and additional sites of lymphadenopathy, as well as other localized potential vaccine-related mass manifestations. In addition to a case of minimal change disease, we report two cases here with associated systemic and local pathologic changes related to COVID-19 vaccination. Methods/Case Report In case #1, a 17-year-old male presented with a 2.4 cm left postauricular mass. He had originally noticed the mass six months prior and thought that it had recently been growing. The mass was soft, nonfluctuant, and nontender to palpation. Given the risk of malignancy, a resection was performed. Histology showed an enlarged lymph node composed of mixed inflammatory cell components consistent with lymphoid hyperplasia and no evidence of malignancy. On further chart review, the patient had received his second COVID-19 vaccination just prior to noticing the mass enlarging. A SARS-CoV-2 Anti-Spike IgG assay was as high as 24,396 AU/ml, suggesting that this benign lymphadenopathy was most likely related to his vaccination. For case #2, a 47-year-old male developed a painless right deltoid mass shortly after receiving his vaccination at the same area that subsequently increased in size over seven months to 6.5 cm. Imaging showed a heterogeneous mass within the deltoid muscle concerning for malignancy and a biopsy was performed. Sections showed wavy, bland spindle cells with nuclei staining diffusely positive for beta-catenin, consistent with fibromatosis at his vaccination site. Results (if a Case Study enter NA) NA. Conclusion In summary, these case reports show potential systemic and local reactive effects in response to COVID-19 vaccination.

A Case Report on Heart Rate Variability Biofeedback and Postconcussion Syndrome: Healing the Autonomic Nervous System

Postconcussion syndrome is a devastating condition of the mind, body, and even personality. Mounting research demonstrates that heart rate variability biofeedback can help the concussed individual in three critical ways: (a) eliciting high amplitude oscillations in cardiovascular functions and thereby strengthening self-regulatory control mechanisms;(b) restoring autonomic balance;and (c) increasing the afferent impulse stream from the baroreceptors to restore balance between inhibitory and excitatory processes in the brain.

Barotrauma in a Previously Healthy and Young COVID-19 Patient: an Autopsy Case Report

Introduction/Objective Since the emergence of a novel SARS-CoV-2 virus caused coronavirus disease 2019 (COVID-19), a great number of autopsy studies have been published. However, histopathologic studies focused on pulmonary barotrauma are very rare. Here we report an autopsy confined to the lungs on a young COVID-19 patient. Methods/Case Report The patient was a 37-year-old male, non-smoker, with no significant past medical history, and a body mass index of 24.1, who presented with shortness of breath and cough. A computerized tomography (CT) showed features of atypical pneumonia. The main abnormal laboratory data included elevated partial thromboplastin time, fibrinogen, and D-Dimer. The patient had been on mechanical ventilation for 35 days, and was complicated by recurrent pneumothoraces, hypotension, and worsening hypoxia. An autopsy limited to the lungs was performed after the patient expired. Grossly, the lungs showed increased weight, adhesions on visceral pleural surface, patchy consolidation and dilated subpleural cysts. Histological examination revealed cystically dilated/remodeled airspaces with extensive coagulative necrosis, focal alveolar hemorrhage and edema, focal confluent fibrosis, and subpleural blebs. Fresh fibrinous thrombi were seen in small- and medium-sized vessels. Viral cytopathic changes or significant inflammation were not observed. The findings in the lungs were consistent with barotrauma in COVID-19. Results (if a Case Study enter NA) NA. Conclusion This case demonstrates various histopathologic changes of the lungs in a previously healthy and young COVID-19 patient with prolonged hospital course of mechanical ventilation. The features of diffuse alveolar damage with inflammation usually seen in the early stage of barotrauma are not identified. Our findings in the lungs may represent the histopathologic characteristics of the later stage of barotrauma in COVID-19.

Comparison of laboratory parameters during herpes zoster infection: a case-control study

Objective: We aimed to find the parameters that can change during herpes zoster infection and observe the relationship of these parameters throughout the disease. Material and Methods: We compared 40 herpes zoster patients and 2 separate control groups, who were healthy and had comorbidities similar in age and gender. Patient files were retrospectively analyzed, and laboratory parameters were compared between groups. The laboratory values of the patient group with herpes zoster were evaluated among themselves according to the duration of the symptoms. Results: Fasting glucose, creatinine, aspartate aminotransferase values, the percentage and the absolute number of monocytes, red blood cell distribution width-coefficient of variation, and C-reactive protein levels of the patients with herpes zoster were significantly higher, and the absolute number of lymphocytes, mean corpuscular volume and platelet distribution width levels were lower than the control groups. The percentage of monocytes in the first 5 days was significantly higher than in the following days, and hematocrit values were lower in the last days. Conclusion: Examining routine laboratory values during diseases may help diagnose the disease, especially in patients with faint clinical signs and zoster sine zoster. In addition, it may be useful to question patients with herpes zoster for renal dysfunction, rheumatological diseases, and malignancy.

PERICARDITIS AFTER COVID-19 VACCINATION: A CASE SERIES

BackgroundCOVID-19 vaccination campaigns successfully impacted on viral spreading and in particular on clinical course of the disease. However, secondary to a highly extended vaccination program, several local and systemic adverse events associated with mRNA COVID-19 vaccines have been reported. Pericarditis and myocarditis are examples of cardiac complications related to these vaccines. In particular, cases of pericarditis have occurred after mRNA COVID-19 vaccination (mostly secondary to vaccination with Moderna than Pfizer-BioNTech), especially in male adolescents and young adults, more often after the second dose. The incidence is approximately of 1-2 cases/100.000.ObjectivesAim of our study was to study the clinical profile of pericarditis occurred within 30 days after COVID-19 vaccines in our clinic.MethodsWe present a case series of patients who developed pericarditis after COVID-19 vaccination in the Department of Internal Medicine at Fatebenefratelli Hospital in Milan, followed from December 1, 2021 to April 15, 2022.ResultsTwenty-five individuals, of which 18 (72%) were women and 7 (28%) were males, had vaccine related pericarditis. Two patients were vaccinated with AstraZeneca, 2 with Moderna, the remaining with Pfizer-BioNTech. Median age was of 42 years. Of all patients, one subject was affected by constrictive effusive pericarditis, while another required treatment of pericarditis with Anakinra, switched to Canakinumab after severe skin reactions, because of failure of therapeutic response to first-line treatments.Two patients required hospital admission, in one case for a transient constrictive pericarditis. In the remaining cases clinical symptoms associated with post-vaccines pericarditis were mild and didn't require hospitalization.Chest pain was reported in 100% of cases, whereas pericardial effusion (in one case larger than 10 mm) was evidenced in 30% of subjects. Eighty percent of patients experienced tachycardia, whereas 90% reported asthenia.An increase in indices of inflammation (CRP) was documented in 50% of patients, usually mild.With regard to therapy, 90% of patients were treated with NSAIDs, 95% with colchicine, while 50% of cases required treatment with low-dose steroids.ConclusionCOVID-19 vaccination induces a particular form of pericarditis, often insidious and very troublesome, but with good prognosis. The clinical phenotype showed less typical chest pain, often normal indices of inflammation and little or no instrumental changes, but patients often experimented tachycardia and functional limitation. With regard to therapy, we used NSAIDs at adequate dosages to control the clinical condition, or low-dose colchicine. Low doses of cortisone (e.g., prednisone 5-10 mg a day) were useful in the presence of marked asthenia or systemic symptoms. Beta-blockers or ivabradine were used in the presence of tachycardia.References[1]Barda N, Children 2021, 8(7), 607;Safety of the BNT162b2 mRNA Covid-19 in a Nationwide setting. N Engl J med 2021;385:1078-1090.[2]Diaz GA, Myocarditis and Pericarditis After Vaccination for COVID-19. JAMA 2021;326 (12): 1210-1212.[3]Bibhuti D, Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination: What Do We Know So Far?. Children 2021, 8(7), 607.[4]Giacomo Maria Viani, Patrizia Pedrotti, Romano Seregni, and Brucato Antonio;Effusive–constrictive pericarditis after the second dose of BNT162b2 vaccine (Comirnaty): a case report;European Heart Journal - Case Reports (2022) 6(2), 1–6.[5]Francesco Perna, Elena Verecchia, Gaetano Pinnacchio, Laura Gerardino, Antonio Brucato, and Raffaele Manna;Rapid resolution of severe pericardial effusion using anakinra in a patient with COVID-19 vaccine-related acute pericarditis relapse:a case report;European Heart Journal - Case Reports (2022) 6, 1–6.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Anesthesia for penetrating injury of the oropharynx in a child: a case report

BackgroundPenetrating injury of the oropharynx occurs frequently in children, however, anesthetic management is seldom described in such cases.Case presentationA 2-year old child came to the emergency room with a toothbrush impacted in the gingivobuccal sulcus making airway management difficult. We used a simple yet unique approach to secure the airway safely given the lack of pediatric size fibreoptic and videolaryngoscopes in our emergency operation theatre. The patient was kept in Pediatric ICU and watched for any complications and discharged on the 4th postoperative day.ConclusionsThus, ingenious non-invasive techniques to secure the airway can prevent the patient from undergoing surgical tracheostomy.

Business on Hold? EMA's Full Recovery in Question

The EMA pandemic Task Force (COVID-ETF) helps EU member states and the European Commission (EC) to take quick and coordinated regulatory action on COVID-19 treatments and vaccines. Delayed submissions As a result of pressure on the work time of regulators from COVID-19 matters, pharmaceutical companies are thought to be holding back the application for marketing authorizations of their products or approval of variations of marketing authorizations. Regulators are not only worried about having to grapple with a rush of delayed submissions but also the extra burden of implementing new EU legislation in areas like veterinary medicine, medical devices, and personal data protection. A joint HMA/EMA Big Data Task Force recommended in December 2019 that the regulatory network set up a platform for access and analysis of healthcare data from across the EU (5).

Unveiling an oral hemangiolymphangioma.

Hemangiolymphangioma is a very rare vascular malformation that develops as a combination of dilated venous and lymphatic vessels. We describe an unusual case of hemangiolymphangioma of the tongue affecting an adult man who complained of an uncomfortable, slowly progressing exophytic irregular dark red-violaceous nodular mass on his tongue that impaired speech and swallowing for two weeks. The clinical differential diagnoses were Kaposi's sarcoma and a COVID-19-related lesion. A complete blood count and serology for HIV-1 and 2 and RT-PCR for COVID-19 were requested and results were negative. An incisional biopsy was performed. Microscopically, the lesion exhibited several dilated vessels lined by normal-appearing endothelial cells, some filled with prominent intravascular erythrocytes and others containing proteinaceous eosinophilic material resembling lymphatic vessels, in close association with hyperkeratosis, papillomatosis, and acanthosis. From immunohistochemical analysis, most vessels were found to be CD34 positive, some highlighted by α-SMA, whereas D2-40 was focal. Positive staining for some lymphatic and blood vessel markers, i.e., D2-40 and CD34, respectively, indicates a mixed derivation of the lesion. HHV-8 was negative. Clinical features, the congested blood vessels with ectasia in intimate association with hyperplastic epithelium, and the immunohistochemical profile supported the final diagnosis of oral hemangiolymphangioma. The patient underwent minimally invasive surgical excision with no intercurrences. After 18 months of follow-up, there were no signs of relapse.

Editors in Chief of Public Health Reports, 1878-2022: Men and Women Who Shaped the Discussion of Public Health Practice From 1918 Influenza to COVID-19.

OBJECTIVES: Public Health Reports (PHR), the official journal of the Office of the US Surgeon General and US Public Health Service, is the oldest public health journal in the United States. Considering its heritage through the eyes of its past editors in chief (EICs), many of whom have been influential public health figures, can provide a fresh point of view on US public health history, of which the journal has been an integral part. Here, we reconstruct the timeline of past PHR EICs and identify women among them. METHODS: We reconstructed the PHR EIC timeline by reviewing the journal's previous mastheads and its articles describing leadership transitions. For each EIC, we identified dates in office, concurrent job titles, key contributions, and other important developments. RESULTS: PHR had 25 EIC transitions in 109 years of its history, during which a single individual in charge of the journal could be identified. Only 5 identifiable EICs were women, who served as EIC for approximately one-quarter of the journal's traceable history (28 of 109 years). PHR's longest-serving EIC was a woman named Marian P. Tebben (1974-1994). CONCLUSIONS: PHR history revealed frequent EIC transitions and a low representation of women among its EICs. Mapping the timeline of past EICs of a historic public health journal can yield valuable insights into the workings of US public health, especially in the area of building a research evidence base.

The lockdown and vaccination distribution in Thailand's COVID-19 epidemic: A model study.

Background: Several countries used varied degrees of social isolation measures in response to the COVID-19 outbreak. In 2021, the lockdown in Thailand began on July 20 and lasted for the following six weeks. The lockdown has extremely detrimental effects on the economy and society, even though it may reduce the number of COVID-19 instances. Our goals are to assess the impact of the lockdown policy, the commencement time of lockdown, and the vaccination rate on the number of COVID-19 cases in Thailand in 2021. Methods: We modeled the dynamics of COVID-19 in Thailand throughout 2021 using the SEIR model. The Google Mobility Index, vaccine distribution rate, and lockdown were added to the model. The Google Mobility Index represents the movement of individuals during a pandemic and shows how people react to lockdown. The model also examines the effect of vaccination rate on the incidence of COVID-19. Results: The modeling approach demonstrates that a 6-week lockdown decreases the incidence number of COVID-19 by approximately 15.49-18.17%, depending on the timing of the lockdown compared to a non-lockdown scenario. An increasing vaccination rate potentially reduce the incidence number of COVID-19 by 5.12-18.35% without launching a lockdown. Conclusion: Lockdowns can be an effective method to slow down the spread of COVID-19 when the vaccination program is not fully functional. When the vaccines are easily accessible on a large scale, the lockdown may terminated.

Lung Aspergillus niger infection after SARS-CoV2

A 64-year-old never-smoker man, with professional exposure, presented to Marius Nasta Pneumophtisiology Institute for fatigability to effort, in the context of severe SARS-COV2 infection one month previously. His medical history includes pulmonary tuberculosis (55 years ago) and newly diagnosed type II diabetes (261 mg/dL glycemia). The thoracic tomography computer in the immediate post-COVID period (Fig. 1A) revealed the presence of glass ground lesions and a 3 cm nodule with cystic degeneration in the upper left lobe. A gross examination of the specimen identified a condensation area of 2.5 cm diameter, brown-grey colored, with necrosis and central ulceration. Microscopic examination showed the presence of bronchiectasis with squamous metaplasia of the epithelium, which appears ulcerated;numerous calcium oxalate crystals with adjacent foreign body granulomatous reaction;endobronchial are present fibrinous and inflammatory debris, brown-black pigment, and septate, dichotomous branching hyphae, suggestive of Aspergillus spp. A periodic acid-Schiff stain was performed, identifying the fungal hyphae. The histopathological diagnosis was bronchiectasis supra-infected and colonized with fungal filaments (Aspergillus niger).