RRC ID 47015
Author Saito T, Shime N, Itoh K, Fujita N, Saito Y, Shinozaki M, Shibuya K, Makimura K, Hashimoto S.
Title Disseminated aspergillosis following resolution of Pneumocystis pneumonia with sustained elevation of beta-glucan in an Intensive Care Unit: a case report.
Journal Infection
Abstract Invasive aspergillosis is a major cause of morbidity and mortality in immunocompromised patients receiving intensive care. The double-sandwich ELISA for galactomannan is reported to have a high sensitivity (96.5%) for the detection of invasive aspergillosis when a cut-off value of 0.8 ng/ml is used. However, we have experienced a case of lethal disseminated aspergillosis in a patient that presented with a negative galactomannan (GM) test and persistent elevation of beta-D glucan (BG) levels. A 63-year-old female was admitted to our Intensive Care Unit (ICU) in acute respiratory failure and elevated BG. She had been receiving medication for Good-pasture syndrome based on anti-glomerular basement membrane antibodies and myeloperoxidase-antineutrophil cytoplasmic antibodies for 9 months and was receiving long-term prednisolone therapy (20 mg/day). On admission, her trachea was immediately intubated, and a PCR analysis of the bronchoalveolar lavage sample revealed Pneumocystis jiroveci. Trimethoprimsulfamethoxazole therapy was started for Pneumocystis pneumonia. The levels of BG remained elevated (> 100 pg/ml) during the treatment period despite the clinical resolution of Pneumocystis pneumonia, raising concerns of another complicated invasive fungal disease; consequently, fosfluconazole was administered empirically. The serum BG levels, however, did not decrease. Blood cultures did not detect a fungal infection. Serum GM levels measured by a double-sandwich ELISA on the 6th, 11th, and 24th days in the ICU were negative (< 0.2 ng/ml). The patient ultimately died of multiple organ failure on the 45th ICU day. Postmortem examination revealed a disseminated fungal infection with aggressive vascular invasion of the lungs, heart, and brain. In situ hybridization with a 568-bp probe of the alkaline proteinase sequence of Aspergillus fumigatus showed specific positive staining within the fungus present in the infected lung tissue, revealing that this patient may have had a systemic infection by A. fumigatus or A. flavus. This is a case of serum GM-negative disseminated aspergillosis pathologically proven by autopsy. Persistent elevated BG levels (> 100 pg/ml) refractory to trimethoprim-sulfamethoxazole and fosfluconazole may suggest possible Aspergillus infection and should prompt the initiation of empiric anti-aspergillosis therapies in patients at risk for fungal infection.
Volume 37(6)
Pages 547-50
Published 2009-12-1
DOI 10.1007/s15010-009-8108-5
PMID 19730788
MeSH Antifungal Agents / therapeutic use Aspergillosis / diagnosis* Aspergillosis / microbiology Aspergillosis / pathology Aspergillus / isolation & purification Brain / microbiology Fatal Outcome Female Galactose / analogs & derivatives Heart / microbiology Humans Immunosuppressive Agents / adverse effects Immunosuppressive Agents / therapeutic use Intensive Care Units Lung / microbiology Mannans / blood Middle Aged Pneumocystis carinii / isolation & purification Pneumonia, Pneumocystis / diagnosis* Pneumonia, Pneumocystis / drug therapy* Pneumonia, Pneumocystis / microbiology Prednisolone / adverse effects Prednisolone / therapeutic use Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use beta-Glucans / blood*
IF 3.04
Times Cited 7
Pathogenic microorganisms