Rapidly Progressive Disseminated Aspergillosis in a Diabetic Patient

ABSTRACT

Invasive aspergillosis is a rapidly progressive, fatal infection that usually occurs in immunocompromised patients. The spectrum of clinical presentation ranges from non-invasive, invasive, destructive and allergic aspergillosis. It is rare to see overwhelming aspergillosis in an immunocompetent host. Nevertheless, certain risk factors such as underlying fibrotic lung disease, suppurative infection, long-term corticosteroid use and uncontrolled diabetes mellitus (DM) have been described. We hereby present a case of invasive pulmonary aspergillosis in a patient with uncontrolled DM. A 60-year-old man with a history of heavy smoking (50- pack-year), poorly controlled DM presented to the hospital with a large area of erythema with eschar over his left posterior thigh. Clinical examination and CT abdomen pelvis confirmed necrotizing fasciitis involving his perineum and left thigh. Admission CT abdomen showed a small left lower lobe infiltrate (Day 1, Panel A). He underwent urgent debridement and intraoperative tissue cultures grew coagulase-negative staphylococcus, Proteus Vulgaris and anaerobic gram-positive rods. He received piperacillintazobactam, vancomycin, and clindamycin for 16 days which was subsequently narrowed to ceftriaxone and metronidazole. He had worsening leukocytosis but all his blood cultures have been negative. Tracheal aspirate gram stain on day 5 showed moderate yeast, and cultures grew Candida albicans and Aspergillus fumigatus. CT scan of his chest showed bilateral reticulonodular opacities with a new loculated right pleural effusion (Day 16, Panel B). Trans-esophageal echocardiogram did not show any right-sided heart valve vegetation. He received intravenous voriconazole for disseminated aspergillosis. Despite of new prophylactic antifungal strategies, more sensitive and rapid diagnostic tests, as well as various efficacious treatments, survival of invasive disseminated aspergillosis remains poor. High clinical suspicion with a proactive investigation approach is the key to minimizing mortality. Various risk factors such as hematopoietic-cell transplantation, neutropenia, solid-organ transplantation, chemotherapy, prolonged ICU stay, structural lung disease, impaired mucociliary clearance after a recent pulmonary infection (including SARS-CoV-2) have been well described. Our case highlights the importance of recognizing uncontrolled DM as a crucial risk factor for disseminated aspergillosis. (Figure Presented).