DISSEMINATED INVASIVE ASPERGILLUS MASQUERADING AS AMIODARONE-INDUCED THYROTOXICOSIS

ABSTRACT

SESSION TITLE Rare Pulmonary Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 0135 pm - 0235 pm INTRODUCTION: Aspergillus is a group of opportunistic endemic fungal species that causes pathology within the respiratory tract and sinuses of individuals with predisposing factors, such as immunosuppression. While less frequently discussed, aspergillosis thyroiditis represents the most common fungal thyroiditis. We present a case of this condition that was misdiagnosed as amiodarone induced thyrotoxicosis. CASE PRESENTATION A 54-year-old male was evaluated in outpatient pulmonary clinic after a chest CT revealed new upper lobe mass-like pleural based infiltrates with accompanying symptoms of dyspnea on exertion and fevers. His medical history was significant for orthotopic heart transplant 6 months ago due to a combination of non-ischemic cardiomyopathy with further decompensation from COVID-19 infection. After transplant, he was diagnosed with thyrotoxicosis secondary to amiodarone that was being treated with prednisone and methimazole. Given the concern for infection on imaging, he was admitted to the hospital and underwent urgent bronchoscopic evaluation. During the procedure, he was noted to have severe extrinsic tracheal compression. His neck imaging was consistent with a nodular goiter. The BAL revealed Aspergillosis fumigatus and he was subsequently treated with isavuconazium. Given the compression on the trachea and persistent dyspnea, the decision was to pursue total thyroidectomy. Surgery occurred 2 months after treatment was initiated for the Aspergillosis and with improvement on serial chest CTs. Pathologic examination of the thyroid tissue revealed extensive invasive aspergillus with abscesses involving both lobes. DISCUSSION: Aspergillus infection leading to disseminated disease typically occurs in individuals that have a compromised immune system such as seen in malignancy, solid organ transplant, chronic steroid use, and poorly controlled diabetes mellitus. Recently, it has been cited that up to 15% of hospitalized COVID-19 patients requiring intensive care develop aspergillus infection. After initial aspergillosis infection has been established, the thyroid gland is a site for dissemination due to its rich vascular supply. In addition, due to the angioinvasive properties of the pathogen, the fungus can breakdown tissue planes and easily travel from its site of origin. Thereby a primary infection in the respiratory tract can lead to dissemination to the neck structures due to its proximity. When thyroid invasion occurs, the common complaints are neck pain and swelling. Thyroid laboratory findings encompass the full spectrum including hyperthyroidism, hypothyroidism, and euthyroid. Given these non-specific findings, clinicians need to be conscious of this disease entity. CONCLUSIONS: In patients with immunocompromising conditions, findings of neck pain, swelling, and abnormal thyroid laboratory values should broaden the differential for clinicians to include aspergillosis thyroiditis. Reference #1 Alvi, Madiha M et al. "Aspergillus thyroiditis a complication of respiratory tract infection in an immunocompromised patient.” Case reports in endocrinology vol. 2013 (2013) 741041. doi10.1155/2013/741041 Reference #2 Marui, Suemi, et al. "Suppurative thyroiditis due to aspergillosis a case report.” Journal of Medical Case Reports 8.1 (2014) 1-3. Reference #3 Kuehn, Bridget M. "Aspergillosis Is Common Among COVID-19 Patients in the ICU.” JAMA 326.16 (2021) 1573-1573. DISCLOSURES No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Honoraria Removed 04/03/2022 by A. Whitney Brown No relevant relationships by A. Whitney Brown, value=Consulting fee Removed 04/03/2022 by A. Whitney Brown No relevant relationships by Kristen Bussa Advisory Committee Member relationship with Boehringer Ingelheim Please note 2019-2021 Added 04/03/2022 by Christopher King, value=Consulting f e Advisory Committee Member relationship with Actelion Please note 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with Actelion Please note 2019-2022 Added 04/03/2022 by Christopher King, value=Consulting fee Speaker/Speaker's Bureau relationship with United Therapeutics Please note 2020-22 Added 04/03/2022 by Christopher King, value=Consulting fee No relevant relationships by Haresh Mani No relevant relationships by Mary Beth Maydosz No relevant relationships by Alan Nyquist No relevant relationships by Anju Singhal No relevant relationships by Amy Thatcher