Invasive Aspergillosis in an Immunocompetent Patient with Fever and a Cardiac Mass

Abstract

Invasive aspergillosis is an often fatal disease that usually occurs in immunocompromised patients. We report a case of invasive aspergillosis presenting as a febrile respiratory infection with a cardiac mass in an immunocompetent patient. Invasive aspergillosis should be considered in the differential diagnosis of an otherwise undiagnosed invasive febrile respiratory illness, even in immunocompetent patients. Echocardio graphy should be performed to evaluate for endocarditis in such cases. Prompt initiation of appropriate antifungal therapy is warranted, even before the diagnosis of invasive aspergillosis is confirmed. Brief ReportA generally healthy 53 year-old male plumber with suboptimally-controlled noninsulin dependent diabetes mellitus (Hb A1c 8) and coronary artery disease s/p CABG 10 years earlier presents to the ED with 10 days of fever and cough. Physical exam reveals a temperature of 36.6°C, blood pressure of 111/70 mmHg, pulse of 108 bpm, respiratory rate of 30, and pulse oxygen saturation of 80% on room air which rises to 95% on 4 liter nasal cannula. There is a regular tachycardia without murmur; rales are present one-quarter up the lung fields bilaterally. Labs are notable for a wbc 15.2 with 73% neutrophils and 8% bands. Electrocardiogram demonstrates sinus tachycardia at 110 beats per minute with an incomplete right bundle branch block pattern. Chest radiography reveals bilateral interstitial infiltrates with small nodules in the right upper and left lower lobes. Moxifloxacin is started for treatment of community-acquired pneumonia. On HD #2 CT angiogram of the pulmonary arteries reveals a small left upper lobe pulmonary embolism and extensive bilateral ground-glass opacities. Lower extremity venous Doppler ultrasound study reveals bilateral DVTs below the knee. Therapeutic enoxaparin injections are started. On HD #3 a bronchoalveolar lavage is performed with washings sent for Gram stain, and bacterial, fungal, AFB, and viral cultures, all of which are negative. Serum human immunodeficiency virus test is negative.Transthoracic echocardiogram performed on HD #3 to assess pulmonary artery pressures and cardiac function reveals normal left ventricular systolic function, an estimated right ventricular systolic pressure of 58 mmHg,

Invasive fungal infection by Aspergillus flavus in immunocompetent hosts: A case series and literature review

“…Fortunately, both patients evolved adequately. This delay has also been reported in previous reports, such LaBarbera et al and Baeesa et al, where appropriate treatment was not started early due to the difficulty in culturing Aspergillus and the unspecific clinical manifestations [10], [11]…”

A Rare Presentation of Cardiac Aspergilloma in an Immunocompetent Host: Case Report and Literature Review

“…Aspergillus is a common fungus that is present in the environment and easily inhaled; however, healthy individuals have a natural immunity to the aspergillus spores. Aspergillus infections account for 0.1-3.9% of annual cases in immunocompromised patients, out of which only 0.7-6% of patients develop cardiac involvement due to the fungal infection [2]. The common predisposing risk factors of an Aspergillus infection are immunocompromised status, damaged lungs, prosthetic valves, rheumatic heart disease, long-term placement of a central venous catheter, total parenteral nutrition, and IV drug use [3-4].…”