IMPORTANCE OF HIGH CLINICAL SUSPICION FOR COVID-19-ASSOCIATED PULMONARY ASPERGILLOSIS IN PATIENTS WITH EQUIVOCAL BIOMARKERS

ABSTRACT

SESSION TITLE Pathologies of the Post-COVID-19 World SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 1015 am - 1110 am INTRODUCTION: Pulmonary aspergillosis is a recognized complication of COVID-19. Options for diagnostic evaluation in patients with suspected pulmonary aspergillosis include serum galactomannan, beta-D-glucan, Aspergillus PCR, fungal cultures and tissue biopsy. Diagnosis is challenging due to the risks and logistical barriers associated with procedural/surgical tissue biopsy and the variable reliability of serum biomarkers. We present a case of a 76-year-old male who developed invasive pulmonary aspergillosis after a COVID-19 respiratory infection. CASE PRESENTATION 76-year-old male with a past medical history that includes emphysematous COPD, history of chronic lymphocytic leukemia in remission, on ibrutinib, who contracted SARS-CoV-2 resulting in hypoxemic respiratory failure and requiring hospital admission and was treated with dexamethasone and remdesivir. He was discharged home and due to his worsening respiratory condition, he was readmitted to the hospital next month. Ct chest performed revealed pulmonary embolism and diffuse multifocal opacification with interspersed scattered dense opacities and nodules with cavitary lesions in the right upper lobe. A bronchoscopy was performed and the Aspergillus antibody test, beta D glucan and galactomannan antigens resulted as negative. Due to this, voriconzaole was discontinued. Subsequently CT-guided lung biopsy demonstrated Aspergillus. Eventually, fungal cultures from BAL began growing fungus. DISCUSSION: Our patient initially presented with a Covid infection in January 2022 he was initially treated with remdesivir, 14 days of baricitinib and 10 days of Decadron followed by a steroid taper (due to his underlying COPD). He did not receive tocilizumab. He was found to have progression of the cavitary lesions during a third admission. We suspect that the main contributing factors for the development of invasive pulmonary aspergillosis are related to interleukin production, distorted architecture from COVID-19 infection and multiple courses of steroids. This case report demonstrates the importance of having a high clinical suspicion for invasive pulmonary aspergillosis in all patients with COVID-19 infection. It also demonstrates that serum biomarkers are not reliable indicators of infection and cannot be used to definitively rule out infection or to exclude treatment with antifungal therapy. It should be noted that positive serum biomarkers in patients with true invasive aspergillosis have a higher mortality rate as compared to those without positive serum biomarkers. This case also underscores the importance of obtaining tissue diagnosis in patients where there is a high suspicion for fungal infection when all other studies are equivocal. CONCLUSIONS: We believe that this case underscores the importance of maintaining a high clinical suspicion for opportunistic and fungal infections in patients with COVID-19, regardless of the serum biomarkers. Reference #1 Arastehfar A, Carvalho A, van de Veerdonk FL, et al. Covid-19 associated Pulmonary Aspergillosis (capa)—from immunology to treatment. Journal of Fungi. 2020;6(2)91. doi10.3390/jof6020091 Reference #2 Machado M, Valerio M, Álvarez-Uría A, et al. Invasive Pulmonary Aspergillosis in the COVID-19 ERA An expected new entity. Mycoses. 2020;64(2)132-143. doi10.1111/myc.13213 Reference #3 Maschmeyer G, Haas A, Cornely OA. Invasive aspergillosis. Drugs. 2007;67(11)1567-1601. doi10.2165/00003495-200767110-00004 DISCLOSURES No relevant relationships by Hira Bakhtiar No relevant relationships by Amanda Lindo No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore