Presentation
Worsening dyspnea, hemoptysis, and weight loss.
Patient Data
Two cavitating lung lesions, one adjacent to the right side of the heart within the right middle lobe measuring 4.9 x 3.3 cm containing minor debris and the second within the right lower lobe adjacent to the oblique fissure measuring 4.6 x 4.2 cm containing an intracavitary body. Bulging of the adjacent fissures with possible spread across the fissures. Bronchial wall thickening in the right lower lobe.
Scattered area of sub-segmental atelectasis within the lungs. No consolidation.
Trancatheter aortic valve replacement.
Gomori methenamine silver (GMS) stain of lung tissue revealing thin, branching hyphae consistent with Aspergillus.
Case Discussion
This case highlights the challenging course of a patient who endured extensive hospitalization due to the complications of COVID-19 viral pneumonia compounded by superimposed bacterial pneumonia and subsequent aspergillosis. Initially the patient demonstrated improvement from the bacterial pneumonia with a combination of antibiotics and a course of steroids. However, at the time of discharge, a CT scan revealed the presence of thick-walled cavities in the right lung.
Despite receiving outpatient antibiotics and corticosteroids for persistent bronchitis-like symptoms, the patient's condition deteriorated over the course of three months. Upon return to the hospital, he reported worsening dyspnea, hemoptysis, and weight loss. CT chest demonstrated an intracavitary mass in the right lower lobe, suggestive of a fungus ball.
Bronchoscopy showed active bleeding, prompting the decision to proceed with a right lower lobe wedge resection. Histopathological examination of the lung revealed thin, branching hyphae and necrotizing granulomas without vascular invasion. Fungal culture of the lung tissue was positive for Aspergillus. Hemorrhage can occur from reactive granulation tissue or tissue invasion.
Antifungal therapy with voriconazole was promptly initiated with clinical improvement and eventual discharge. Subsequent monitoring and a three-month follow-up period demonstrated a resolution of the cavitary lesions.
This case emphasizes the potential long-term sequelae and complications associated with COVID-19 pneumonia and prolonged corticosteroid use, both of which predispose to pulmonary aspergillosis.
Co-authors: Ahmad Munir DO, Zoha Huda MD, Nazir Ahmad Lone MD
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