Influenza-Associated Disseminated Aspergillosis in a 9-Year-Old Girl Requiring ECMO Support

A previously healthy 9-year-old girl developed fulminant myocarditis due to severe influenza A infection complicated with methicillin-resistant Staphylococcus aureus pneumonia, requiring extracorporeal membrane oxygenation (ECMO) support. Twelve days after admission, Aspergillus fumigatus was isolated in tracheal aspirate, and 12 h later she suddenly developed anisocoria. Computed tomography (CT) of the head showed fungal brain lesions. Urgent decompressive craniectomy with lesion drainage was performed; histopathology found hyphae in surgical samples, culture-positive for Aspergillus fumigatus (susceptible to azoles, echinocandins, and amphotericin B). Extension workup showed disseminated aspergillosis. After multiple surgeries and combined antifungal therapy (isavuconazole plus liposomal amphotericin B), her clinical course was favorable. Isavuconazole therapeutic drug monitoring was performed weekly. Extensive immunological study ruled out primary immunodeficiencies. Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) follow-up showed a gradual decrease in fungal lesions. Influenza-associated pulmonary aspergillosis is well-recognized in critically ill adult patients, but pediatric data are scant. Clinical features described in adults concur with those of our case. Isavuconazole, an off-label drug in children, was chosen because our patient had severe renal failure. To conclude, influenza-associated pulmonary aspergillosis is uncommon in children admitted to intensive care for severe influenza, but pediatricians should be highly aware of this condition to enable prompt diagnosis and treatment.

A Rapidly Enlarging Thyroid Nodule- Aspergillus Abscess

Introduction: Acute suppurative thyroiditis is a rare thyroid disorder with high mortality often due to bacterial or fungal infection. Here we present a case of a rapidly enlarging thyroid nodule in the setting of disseminated aspergillosis. Case: A 31 year old female with lupus on immunosuppressants first presented with weakness to the emergency department with workup finding multiple pulmonary, intracranial and vertebral lesions and a left thyroid nodule. On thyroid ultrasound the nodule was solid, hypoechoic, 1.5x2.3x2.7cm with irregular margins and no echogenic foci. Thyroid function tests: Total T3 52ng/dL (80-210ng/dL), Free T4 2.26ng/dL (0.6-1.12ng/dL), TSH 0.015µIU/mL (0.45-4.12µIU/mL). The patient was started on voriconazole for disseminated aspergillosis with plan for outpatient thyroid workup. However with further brain lesion growth, the patient was readmitted with incidental finding of thyroid nodule developing into a multiloculated, septated, fluid filled 5x2.9x4cm lesion after 3 months. Fine needle aspiration of the thyroid lesion resulted in negative bacterial and fungal cultures, no malignant cells, positive fungal elements consistent with aspergillus on cytology. The patient was continued on antifungal therapy (switched to cresemba due to voriconazole side effects) with thyroid lesion regression to 2.4x0.6x1.3cm at 6 months and 1.8x1.1x1.6cm at 12 months. Her thyroid function test normalized ~ 1 month after initial set of labs and the patient remained clinically euthyroid throughout her course. Discussion: Thyroid infections are limited due to the thyroid’s high iodine content, capsular encasement and rich vascularity. Acute suppurative thyroiditis (AST) due to aspergillus is a rare finding that can present solo or as a part of disseminated infection especially in immunocompromised individuals. Early presentation is often asymptomatic with possible thyroid function test abnormalities that self resolve in a couple weeks. Occasionally patients present with obstructive symptoms or findings of thyroid storm. Diagnosis is done through fine needle aspiration or autopsy, with treatment options including surgery, antifungals or both. Due to the high mortality of fungal AST, with improved outcomes with early diagnosis, it is important to consider AST as a part of the differential diagnosis in immunocompromised patients with systemic illness.

“Chronic Disseminated Aspergillosis,” a Novel Fungal Immune Reconstitution Inflammatory Syndrome

We report a case of chronic hepatosplenic aspergillosis following immune reconstitution complicating colic aspergillosis in an AIDS patient with multicentric Castleman disease. Symptoms mimicked the clinical presentation of chronic disseminated candidiasis and responded to corticosteroid. This emerging entity enlarges the spectrum of fungal immune reconstitution inflammatory syndrome in the HIV setting.

Fatal Disseminated Aspergillosis in a Patient with Systemic Lupus Erythematosus

Patients with systemic lupus erythematosus (SLE) are at increased risk for infection including opportunistic infections. Fungal infection in particular can be difficult to diagnose and treat and often can be life-threatening in the immunocompromised patient. We present a case in which a patient with SLE presented to the hospital with shortness of breath and cough. Throughout the hospital course, the patient’s condition continued to decline leading to acute respiratory failure, and eventually, the patient expired. Postmortem autopsy revealed invasive fungal aspergillosis infection involving the heart, lungs, and brain. Earlier diagnosis and treatment with empiric antifungals may improve survival in these patients.

Rapid Diagnosis of Invasive Aspergillosis and Active Hepatitis-B Virus Co-Infection in a HIV-1 Infected Patient Using Cell Free DNA Sequencing

Multiple simultaneous opportunistic infections in Human Immunodeficiency virus-1/Acquired immunodeficiency syndrome (HIV-1/AIDS) is a known and dreaded occurrence that often leads to poor outcomes. We present a case of disseminated aspergillosis and active Hepatitis-B virus (HBV) infection in such a host, where cell free DNA (cfDNA) next generation sequencing (NGS) of plasma was used to expedite diagnosis. Bronchoscopy was avoided and treatment was started expeditiously. In this case report we discuss the interpretation of the cfDNA NGS, and its potential role for early diagnosis and avoidance of invasive testing.