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DOUBLE TROUBLE: COVID-19 PNEUMONIA CONCURRENT WITH COVID-19 ASSOCIATED PULMONARY ASPERGILLOSIS (CAPA)
Journal of General Internal Medicine ; 37:S447-S448, 2022.
Article in English | EMBASE | ID: covidwho-1995714
ABSTRACT
CASE A 52-year-old male with a past medical history of asthma and uncontrolled OSA presented to the ED ten days after diagnosis of COVID-19 with worsening dyspnea. He had a history of fluticasone propionate and fluticasone salmeterol use for asthma exacerbations. He endorsed cough, fever, chills, and diarrhea, and denied chest pain, leg edema, and anosmia.Vitals showed oxygen saturation of 65%. CBC demonstrated leukopenia consistent with COVID- 19 infection. Blood labs showed hyperglycemia (blood sugar 182 mg/dL, hemoglobin A1c 9.6%). Bilateral crackles were noted on exam. He was placed on high-flow nasal cannula (HFNC) immediately due to critical hypoxemia. CT PE was negative;CXR revealed bilateral opacities consistent with COVID-19 pneumonia. He started on dexamethasone and remdesivir and was admitted to the MICU for acute hypoxemic respiratory failure. Notably, the patient had no known diagnosis of diabetes mellitus and was started on sliding scale insulin and Lantus. Barcitinib was added in the MICU in addition to linezolid and cefepime for fear of bacterial superinfection but were discontinued after receiving negative cultures. He was transferred out of the MICU four days later after successful weaning of oxygen but soon returned due to worsening oxygen needs. New leukocytosis prompted a repeat respiratory culture, which grew mold on the preliminary read. Voriconazole was initiated due to concern for Aspergillus infection and was continued with confirmation on the final read. Repeat CT showed left pneumomediastinum, right apical pneumothorax, and worsening bilateral opacities. Despite ongoing treatment, the patient required NC at rest and HFNC with minimal exertion. He was discharged home with HFNC. IMPACT/

DISCUSSION:

CAPA is a result of opportunistic fungal infection, causing devastating disease in the immunocompromised. A crucial risk factor is the use of high-dose corticosteroids for a prolonged period. The diagnosis of CAPA is based on a combination of imaging, microbiology, and clinical presentation. Peripheral nodules, air crescent, reverse halo sign, nodular consolidation, ground-glass opacities, crazy paving pattern, pleural effusion, and pulmonary cysts have been reported among CAPA patients. A fungal culture and galactomannan test from respiratory specimens can aid in early diagnosis. The usual presenting symptoms of CAPA include refractory fever, pleuritic chest pain, or dyspnea. Voriconazole is a first-line anti-Aspergillus agent.

CONCLUSION:

Clinical presentation of CAPA is often subtle but associated with high morbidity and mortality. Multiple reports add support to our observation that CAPA can be a result of worsening COVID-19 pneumonia. Early diagnosis and treatment are vital to prevent worse clinical outcomes. Physicians should demonstrate a heightened awareness of the risk of developing CAPA in critically ill COVID-19 patients. Clinicians should exercise low thresholds to identify and treat CAPA, especially in patients on high-dose steroids long-term.
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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Journal of General Internal Medicine Year: 2022 Document Type: Article

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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Journal of General Internal Medicine Year: 2022 Document Type: Article