Pleural aspergillosis with pulmonary artery thrombosis as a complication of Covid-19

ABSTRACT

Background: COVID-19 is associated with an increased risk of superimposed bacterial and fungal infections. Pleural aspergillosis is an uncommon manifestation of invasive aspergillosis. We report a case of pleural aspergillosis with pulmonary artery thrombosis after COVID-19 with favourable outcome. Case Study A 67-year male, diabetic, IHD post CABG, with moderate COVID-19 disease 2 months ago, presented with 1 week history of productive cough, breathlessness and chest pain. Examination revealed hypoxia, tachycardia and diminished breath sounds on right side. Right hydropneumothorax was noted on imaging, tube thoracostomy was done. Pleural fluid investigations were suggestive of pyothorax. CECT-thorax showed cavitary consolidation in right lower lobe. Patient was treated with IV antibiotics. However, there was persistent air leak and tachycardia. 2D-ECHO showed mild PAH. D-Dimer was high, CTPA revealed partial thrombosis of right posterior basal pulmonary arteries. Pleural fluid fungal culture yielded Aspergillus fumigatus. Patient was initiated on oral voriconazole and anticoagulants. He showed marked improvement and in 5 days ICD was removed. Patient is on regular follow-up. Discussion: COVID-19 associated superimposed infections have been reported with high mortality rates. The use of corticosteroids and/or IL-6 antagonists have been implicated with the fungal infections. Pleural aspergillosis is rare. Diagnosis is usually based on clinical and microbiological evidence. A key finding in invasive aspergillosis is angioinvasion which leads to thrombosis and tissue infarction. Conclusion: Clinicians should have high index of suspicion for superimposed fungal infections in COVID-19. Early initiation of treatment brings down morbidity and mortality.