POST-COVID-19-ASSOCIATED ASPERGILLUS EMPYEMA AND PARENCHYMAL ABSCESS

Mir, Mahnoor; Jones, Lara; Levine, Stephanie

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with an increased risk of superimposed bacterial and fungal infections. Invasive aspergillosis has been found in critically ill COVID patients. Despite this strong association, there are no reports of aspergillus empyema related to COVID-19 pneumonia. Here, we present a case of post COVID-19 pneumonia complicated by aspergillus empyema and abscess. CASE PRESENTATION: A 38-year-old woman with a history of poorly controlled type II diabetes mellitus, and uncomplicated asymptomatic COVID-19 pneumonia 2 months prior, presented with 1 month of worsening productive cough, pleuritic chest pain, dyspnea, and fatigue. On admission, she was afebrile, tachycardiac, tachypneic with decreased right sided breath sounds and rhonchi. Her initial labs revealed a white blood cell count of 11.18 k/mcL, a chest x-ray revealed a right posterior lung field cavity with air-fluid level with right upper and lower lung field opacification (Fig. 1). Chest CT showed a right 16 x 5.5-centimeter rim enhancing consolidative opacity with air-fluid level and effusion (Fig. 3). Ultrasound guided thoracentesis revealed frank pus with pleural fluid studies pertinent for glucose 281 mg/dl, total protein 3.7 mg/dl, and fungal culture positive for Aspergillus niger. She underwent right-sided 14-french pigtail catheter placement to drain the empyema and was discharged to complete 4 weeks of oral levofloxacin, metronidazole, and isavuconazole for 6 weeks. Her symptoms resolved on 3 months follow up and imaging showed improvement in right lung field fluid collections with residual lung scarring and fibrosis (Fig. 3). DISCUSSION: COVID-19 associated pulmonary aspergillosis (CAPA) has been reported in multiple case series in hospitalized individuals with severe acute respiratory distress syndrome with high mortality rates.1The use of corticosteroids and anti-IL6 drugs has shown an increase in susceptibility to superimposed infections.2,3 Diagnosis of CAPA generally requires a recent history of COVID-19 pneumonia with clinical worsening, abnormal thoracic radiography, and aspergillus recovered on culture or microscopy. Treatment includes either voriconazole or isavuconazole as the first line agent unless resistance is suspected. We report the first case of COVID-19 associated Aspergillus niger lung abscess empyema in a post-COVID patient. CONCLUSIONS: It is imperative for clinicians to have a high index of suspicion for superimposed fungal infections associated with COVID-19 even in those without the more well-described risk factors of prior tretament with corticosteroids and/or IL-6 agents, due to the risk of significant mortality and morbidity. Early initiation of treatment with close surveillance to include thoracic imaging should be done for patients who develop post COVID-19 necrotizing pneumonia. REFERENCE #1: van Arkel ALE, Rijpstra TA, Belderbos HNA, van Wijngaarden P, Verweij PE, Bentvelsen RG. COVID-19-associated Pulmonary Aspergillosis. Am J Respir Crit Care Med. 2020;202(1):132-135. doi:10.1164/rccm.202004-1038LE REFERENCE #2: Koehler P, Bassetti M, Chakrabarti A, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance [published online ahead of print, 2020 Dec 14]. Lancet Infect Dis. 2020;S1473-3099(20)30847-1. doi:10.1016/S1473-3099(20)30847-1 REFERENCE #3: 3. Bartoletti M, Pascale R, Cricca M, et al. Epidemiology of invasive pulmonary aspergillosis among COVID-19 intubated patients: a prospective study [published online ahead of print, 2020 Jul 28]. Clin Infect Dis. 2020;ciaa1065. doi:10.1093/cid/ciaa1065 DISCLOSURES: No relevant relationships by Lara Jones, source=Web Response No relevant relationships by Stephanie Levine, source=Web Response No relevant relationships by Mahnoor Mir, source=Web Response