Invasive aspergillosis associated with systemic lupus erythematosus and cardiac postoperative complication
A 45-year-old hypertensive male with a prior history of cardiac insufficiency was admitted with symptoms of acute onset of pain in both legs of two weeks duration and with pain in the right leg increasing gradually for the past one week. Investigations revealed normal scores of hemoglobin, 11.5 g%; urea, 25 mg dl-1; creatinine, 0.7 mg dl-1 and glucose, 95 mg dl-1. An aortogram undergone on the first day after admission revealed total occlusion of right common iliac artery and left common femoral arteries, following which he underwent a bilateral femoral embolectomy on the second post admission day.\nThe clot from the femoral artery was sent to the microbiology laboratory for culture, which grew A. fumigatus on solid media after 48h of incubation (,). On the first postoperative day (POD) he was started on amphotericin B at 0.25 mg kg-1 day-1 gradually increasing to 1 mg kg-1 body weight as an intravenous infusion. However, this had to be withheld from the second POD due to elevated renal parameters and nephrotoxicity.\nA transesophageal echocardiography revealed fungal growth on the aortic valve which was mildly thickened. An embolectomy specimen and portions of the native aortic valve were also sent to the Medical Mycology Laboratory (Federal University of Pernambuco) for direct examination and culture. A 20% KOH preparation revealed broad septate dichotomously branched hyphae. Small portions of the specimens were inoculated on routine media such as Sabouraud dextrose agar with 50mg chloranphenicol/L. Cultures were incubated at room temperature and at 37ºC. After 48h of incubation the specimens cultured exhibited fungal growth typical of Aspergillus spp. Identification through macroscopic and microscopic characteristics was conducted according to Hoog et al. () and Rapper and Fennel ().\nThe patient suddenly developed ventricular tachycardia and ventricular fibrillation and had a sudden cardiac arrest and was immediately intubated and put on ventilatory support. The patient rapidly went to fatal outcome, showing signs of fungal sepsis, including massive increase in leukocyte count, acute phase parameters and abnormal liver function tests.