Disseminated enteroinvasive aspergillosis in a critically ill patient without severe immunocompromise
A 47-year-old man with a history of hepatitis C, hemophilia A managed on home Factor VIII and, recently, diagnosed ulcerative colitis on prednisone 40 mg for 10 days was transferred to our facility for concern for toxic megacolon and admitted to the medical intensive care unit (MICU). Admission vital signs were temperature 34.4°C, heart rate 96 bpm, blood pressure 107/51, respiratory rate 14 breaths per minute and oxygen saturation 97% on 3 l/min by nasal cannula. On physical examination, the patient was cachectic and his abdomen was distended and diffusely tender but without rebound tenderness or guarding. The rectal examination was positive for gross blood. A non-contrast abdomen and pelvis computed tomography (CT) scan was significant for pancolitis and the patient was started on antibiotics.\nEmergency general surgery was consulted, and the patient was transferred to the surgical intensive care unit (SICU). The patient developed hypotension requiring vasopressors and respiratory failure requiring mechanical ventilation. Over the next 2 days, leukocytosis and lactic acidosis normalized, and the patient was weaned off vasopressors and extubated. Clostridium difficile antigen was negative and antibiotics were narrowed.\nOn hospital day 6, the patient complained of sudden onset sharp abdominal pain and developed peritoneal signs on abdominal examination. Non-contrast abdominal CT scan demonstrated pneumoperitoneum, colitis and ascites. In the context of the patient's co-morbidities, the patient was deemed too high a surgical risk for exploratory laparotomy. The patient was taken to the operating room for a loop ileostomy rescue procedure. Intraoperatively, the small bowel appeared normal, and ascites appeared clear. The patient was extubated postoperatively and initially improved.\nOn postoperative day 3, he developed supraventricular tachycardia, respiratory failure requiring mechanical ventilation, hypotension requiring vasopressors and large-volume serosanguinous ascites drainage from the intra-abdominal drain. Concurrently, intraoperative ascites cultures grew Candida, Methicillin-resistant Staphylococcus aureus, and E. coli and appropriate antibiotic therapy was initiated. Sputum cultures grew 1+ Aspergillus fumigatus. A repeat endotracheal (ET) aspirate culture was negative for fungus, and a non-contrast chest CT scan demonstrated no evidence of a fungal pneumonia. For the next week, the patient remained intubated but was successfully weaned off vasopressors, and his abdominal examination improved.\nOn postoperative day 14, peritoneal signs and acute hypotension requiring vasopressors recurred. The patient developed black ileostomy output, bleeding from the intra-abdominal drain and bright red blood per rectum. The patient underwent an emergent exploratory laparotomy. Intraoperatively, the small bowel was necrotic from the distal jejunum to the distal ileum. Seventy-three centimeters of small bowel were resected, and a primary anastomosis was performed.\nPostoperatively, the patient had profuse, uncontrollable intra-abdominal bleeding and remained hemodynamically unstable. Despite massive transfusion and aggressive attempts to correct coagulopathy, the patient continued to deteriorate. Goals of care were changed to comfort measures, and the patient died the next morning. Concomitantly, a third ET aspirate culture was positive for 2+ A. fumigatus. The family refused autopsy.\nPathologic evaluation of the resected bowel revealed hemorrhagic, gangrenous bowel (Fig. ) and granular friable, ulcerated mucosa (Fig. ). Microscopically, there were areas of transmural bowel necrosis (Fig. ) and fungi within the bowel wall, artery wall and lumen (Fig. ). Gomori Methenamine Silver stain was characteristic of Aspergillus species (Fig. ).