Invasive Pulmonary Aspergillosis in the Recovery Phase of COVID-19

A 61-year old man was admitted to the intensive care unit for acute respiratory distress syndrome after presenting with four days of dyspnea. Chest imaging revealed diffuse ground glass opacities and he was found to be positive for SARS-CoV-2 infection. His hospital course was complicated by sequelae of coronavirus disease 2019 (COVID-19) including prolonged mechanical ventilation and renal failure requiring hemodialysis. He never received steroids or other immunosuppressive therapy. After one month, he developed new fevers and thick respiratory secretions. Repeat SARS-CoV-2 PCR at this time was negative. Repeat chest imaging revealed a new right upper lobe cavitary lesion. Differential diagnosis at that time included a developing lung abscess and invasive fungal infection. Tracheal cultures and non-bronchoscopic alveolar lavages were collected and serum galactomannan was sent. Due to ongoing need for mechanical ventilation and persistent secretions, empiric broad spectrum antibiotics and amphotericin B (to include mucormycosis coverage) were started. Cultures initially revealed mold finalized as Aspergillus fumigatus. Antifungal therapy was tailored to voriconazole. His fevers ultimately resolved, and he was weaned to minimal ventilator settings in preparation for tracheostomy. Invasive pulmonary aspergillosis is a serious infection that can cause severe systemic dysfunction. On imaging, aspergillosis can appear as solitary or multiple pulmonary nodules or masses with a halo, or reverse halo sign. Peripheral areas of consolidation, with or without cavitation, with adjacent pleural thickening and potentially direct invasion into the adjacent chest wall may be seen in advanced cases. Co-infection with aspergillosis in COVID-19 is a newly recognized phenomenon. There is ongoing discussion regarding appropriate evaluation and empiric, perhaps even prophylactic, use of antifungal therapy. Our case was diagnosed after presumed resolution of SARS-CoV-2 infection bringing to question the role for routine fungal disease evaluation in so-called recovered individuals with on-going respiratory compromise.