Images in… BMJ Case Rep: first published as 10.1136/bcr-2020-234843 on 17 March 2020. Downloaded from niger fungemia secondary to chronic pulmonary in a patient with invasive squamous cell carcinoma Caitlyn Hollingshead ‍ ‍ , Kelly Luttmann, Emad Abu Sitta, Hend Elsaghir

Infectious Diseases, University of Description Toledo Medical Center, Toledo, A- 46-­year old­ man presented with shortness of Ohio, USA breath and increased tracheal respiratory secretions. His medical history included a stroke 6 months prior Correspondence to with resultant chronic hypoxic respiratory failure Dr Emad Abu Sitta; emademad70@​ ​hotmail.com​ with tracheostomy placement, recently diagnosed thyroid-­invasive squamous cell carcinoma and a 30 Accepted 7 March 2020 pack-year­ history of smoking. He had recently been hospitalised and treated with ampicillin–sulbactam for aspiration pneumonia and had undergone left superior thyroid artery embolisation due to tracheal bleeding secondary to invasion of the trachea by the malignant mass. cultures drawn on admission Figure 2 Patient's CT chest with bilateral pulmonary due to concerns for revealed Aspergillus niger nodules and emphysematous changes. in one out of two sets (figure 1A and B). Vital signs revealed tachypnea and increased oxygen requirements but were otherwise unre- was negative. At the time of the bronchoscopy, the markable. Physical examination revealed bilateral patient had received 4 days of vancomycin and rales of the lower lung fields and copious secretions piperacillin–tazobactam and 2 days of voriconazole. noted in the endotracheal tube. Laboratory investi- The patient was treated with voriconazole for gations were significant for a mild leucocytosis. A 6 weeks with significant improvement noted in his chest X-ray­ revealed no cardiopulmonary abnor- respiratory status. malities. CT angiography of the chest performed A. niger is a ubiquitous hyaline mould marked http://casereports.bmj.com/ a month prior to admission revealed emphysema- by its large, biseriate conidia that cover the entire tous changes and bilateral pulmonary nodules, the vesicle.1 The role of A. niger in invasive disease has largest measuring up to 1.7 cm (figure 2), along with been less described than other species. This is likely poorly defined fascial planes in the neck concerning due to the fact that its large conidia do not easily for oedema. CT of the neck revealed extensive reach deep into lung tissues. Invasive aspergillosis infiltrative neoplasm around the native laryngeal largely affects those with profound, prolonged and supraglottic region with occlusion of the right , however, is known to affect critically jugular vein and encasement of the right carotid ill patients, especially those with chronic obstruc- artery. The patient underwent bronchoscopy and tive pulmonary disease.2 Fungemia due to Asper-

bronchoalveolar lavage (BAL) which was found to gillus species is rare, with only 30 cases noted in on September 28, 2021 by guest. Protected copyright. be positive for Aspergillus galactomannan antigen the literature in one review.3 In the critically ill with an index of 4.87, although the fungal culture population, galactomannan from BAL fluid is more sensitive than serum galactomannan and a cut-off­

Learning points

►► Aspergillus fungemia is a rare sequela of pulmonary aspergillosis. Critical illness and chronic obstructive pulmonary disease (COPD) © BMJ Publishing Group are important risk factors for developing Limited 2020. No commercial invasive disease. re-use­ . See rights and ►► Galactomannan from bronchoalveolar permissions. Published by BMJ. lavage fluid is more sensitive than serum To cite: Hollingshead C, galactomannan for diagnosing invasive Luttmann K, Abu Sitta E, aspergillosis in critically ill patients with COPD. et al. BMJ Case Rep ►► Malignancy with angioinvasion in an already Figure 1 (A, B) Aspergillus niger recovered from blood 2020;13:e234843. colonised host may be an additional risk factor doi:10.1136/bcr-2020- on sabouraud dextrose slant and microscopy from the for developing fungemia with Aspergillus. 234843 sample stained with lactophenol cotton blue.

Hollingshead C, et al. BMJ Case Rep 2020;13:e234843. doi:10.1136/bcr-2020-234843 1 Images in… BMJ Case Rep: first published as 10.1136/bcr-2020-234843 on 17 March 2020. Downloaded from of 0.8 has been suggested for diagnosis of invasive disease.4 In ORCID iD this case, the patient's thyroid mass with encroachment on the Caitlyn Hollingshead http://orcid.​ ​org/0000-​ ​0002-2806-​ ​1409 trachea associated with recurrent bleeding may have facilitated entry of Aspergillus into the patient's bloodstream. References 1 Bennett JE, Dolin R, Mandell BMJ. Douglas, and Bennetts principles and practice of Contributors CH: manuscript writing, literature review; KL, EAS and HE: infectious diseases. Philadelphia, PA: Elsevier, 2020. manuscript editing, literature review. 2 Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax 2015;70:270–7. Funding The authors have not declared a specific grant for this research from any 3 Duthie R, Denning DW. Aspergillus fungemia: report of two cases and review. Clin funding agency in the public, commercial or not-­for-­profit sectors. Infect Dis 1995;20:598–605. Competing interests None declared. 4 He H, Ding L, Sun B, et al. Role of galactomannan determinations in bronchoalveolar lavage fluid samples from critically ill patients with chronic obstructive pulmonary Patient consent for publication Obtained. disease for the diagnosis of invasive pulmonary aspergillosis: a prospective study. Crit Provenance and peer review Not commissioned; externally peer reviewed. Care 2012;16:R138.

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2 Hollingshead C, et al. BMJ Case Rep 2020;13:e234843. doi:10.1136/bcr-2020-234843