Invasive Pulmonary Aspergillosis after Influenza A Infection in an Immunocompetent Patient
A 60-year-old man was admitted chiefly with shortness of breath, pleural chest pain. The patient presented with fever, cough, and whitish sputum 10 days prior to consultation. Treatment was received from a local hospital for upper respiratory tract infection, but no improvements were observed. The patient was transferred to our hospital presenting with shortness of breath and pleural chest pain.\nUnderlying disease includes hypertension, and the patient has been taking medication for 20 years.\nHe was a non-smoker and did not have alcohol abuse history.\nAt the time of consultation, the blood pressure was 120/70 mm Hg; heart rate, 102 beats/min; respiratory rate, 24 breaths/min; and body temperature, 38.1℃. The patient was conscious but showed acute ill-looking appearance. Physical examination showed normal conjunctiva with no palpable lymph nodes around the neck. On auscultation of the chest, coarse breathing sounds without wheezing in both lower lung fields were heard. The abdomen was soft, and bowel sounds were normal; no hepatomegaly and splenomegaly were noted. Skin lesions were not observed.\nIn the peripheral blood test, leukocytes were 7,650/mm3 (neutrophils, 79.3%; lymphocytes, 12.3%; and eosinophils, 0.8%); hemoglobin, 14.9 g/dL; platelets, 124,000/mm3; and erythrocyte sedimentation rate, 20 mm/hr (reference range, 0-20 mm/hr). C-reactive protein was 175 mg/dL (reference range, 0-3 mg/dL). In serum biochemistry, blood urea nitrogen/creatinine was 11.9/1.1 mg/dL; total protein/albumin, 6.3/3.6 g/dL; Ca/P, 7.7/2.7 mg/dL; aspartate aminotransferase/alanine aminotransferase, 43/36 IU/L; and total bilirubin, 0.83 mg/dL. For the hepatitis test in autoimmune serology screening, surface antigen of the hepatitis B virus and anti-hepatitis C virus were negative; anti-hepatitis B surface antigen was positive; in the thyroid function test results, T3 was 70.8 ng/dL (reference range, 58-159 ng/dL), whereas thyroid stimulating hormone was 0.701 µIU/mL (reference range, 0.35-4.94 IU/mL) and free T4 was 1.25 ng/dL (reference range, 0.7-1.48 ng/dL); and human immunodeficiency virus and venereal disease research laboratory results were negative. Serum level of IgA, IgG and IgM were within normal range. CD4 count was within normal. Although urinalysis did not show pyuria, microscopic hematuria and proteinuria were observed.\nChest radiography revealed focal consolidation in the right lower lung field, but no cardiomegaly.\nMultifocal ground glass opacities and peribronchial infiltration in both lungs were observed ().\nThe patient presented shortness of breath and pleural chest pain. Chest radiographic findings showed focal consolidation in the lung. Therefore, ceftriaxone+azithromycin were administered since community-acquired pneumonia was suspected. However, fever persisted and hypoxia worsened, and thus, the medication was changed to piperacillin/tazobactam+levofloxacin. However, fever, worsening hypoxia (SpO2, 82.3%; PO2, 43.7 mm Hg), and chest radiographic findings worsened in addition to worsening of the leukocytosis (13,890/mm3). Since community-acquired methicillin-resistant Staphylococcus aureus infection was suspected, vancomycin was administered, and bronchoscopy was performed.\nDiffuse mucosal hyperemia and wide, raised, and cream-colored plaques (pseudomembrane formation) were observed throughout the trachea and both main bronchi, without significant airway obstruction (). Polymerase chain reaction test for influenza A from bronchoalveolar lavage was positive.\nNumerous branching septate hyphae with acute angles less than 45° were observed ().\nThe characteristic septate hyphae of Aspergillus were observed in biopsy. Voriconazole was administered, and the patient was discharged as improvements were observed in the patients fever, hypoxia (SpO2, 97.7%; PO2, 91.0 mm Hg), and leukocytosis (6,270/mm3). However, we were not able to further test for patient's financial reasons.