Title: COVID-19 and Pulmonary Aspergillus

Submitted by: Elizabeth Thottacherry, Peter Pappas

Institution: UAB

Email: ppappas@uabmc.edu

Date: 2/12/21


Chief Complaint:   63 year old male, presents with shortness of breath and positive SARS-CoV 2 (COVID-19)

Medical Hx Family Hx

Coronary artery disease Father- Renal Cancer

Hypertension Social Hx:

Hyperlipidemia Denies substance abuse, smoking

Asthma Rare alcohol, no history of binge drinking

Chronic back pain

Moderate Obesity (BMI 27 kg/m2

Surgical Hx

Percutaneous coronary intervention

Knee Surgery


PresentNot Present
DiaphoresisSore Throat
Body AchesRhinorrhea

MEDICATIONS – at admission

Aspirin 81mg PO daily

Clopidogrel 75mg PO daily

Dexlansopraxole 30 mg PO daily

Lisinopril/Hycrochlorothiazide 10mg/12.5 mg PO daily

Meloxicam  7.5mg PO daily

Clonazepam 1mg PO BID, as needed


Vital signs: 

Temp: 99.8 F/37.7 C, HR: 81 bpm, RR: 20 breaths/min, BP: 146/81 mmHg, Weight: 250lb

General : Alert and oriented in no distress

HEENT: Normocephalic, supple neck, trachea midline, extraocular movements intact, moist oral mucosa

Respiratory: Clear bilaterally, tachypneic

CVS: S1, S2, RRR, no murmurs

GI: Soft, non-distended, BS + 

Neurology: Oriented, no focal deficits



Na – 127 mmol/L

K – 3.9 mmol/L

Cl – 92 mmol/L

HCO3 – 26 mmol/L

BUN – 17 mg/dl

Creatinine – 0.9 mg/dl

Glucose – 110 mg/dl

Ca – 9.0 mg/dl

Total Protein –7.1 gm/dl

Albumin –  

Total Bilirubin – 0.9 mg/dl

AST – 144 units/L

ALT – 220 units/L

ALP – 125 units/L


WBC – 8.38 x 103/cmm

Hb – 15.1 gm/dl

HCT – 45%

Platelets – 210 x 103/cmm

%PMNLs – 79

%Lymphocytes – 13

%Eosinophils –  0

Other labs

LDH – 586 units/L (120 – 240 units/L)

Troponin – 6 ng/L (3 – 20 ng/L)

Ferritin – 2029 ng/ml (23.9 – 226.2 ng/ml)

ESR – 60 mmg/hr (0 – 10 mm/hr)

D dimer – 372 ng/ml (0 – 240 ng/ml)

ESR – 752 mg/dl (220 – 498 mg/dl)

Urinalysis – unremarkable



COVID 19 Diagnosis/Timeline:  

Day -9: Shortness of breath, fever, loss of taste

Day -6: COVID Test positive at outside facility

(Prednisone and Azithromycin- duration unclear

Day -5: pleuritic chest pain, persistent cough, nausea, anorexia

Day 0: Sp02 87% on room air, put on nasal cannula 2L 02 advanced to 6L 02

Medications Added:  Dexamethasone, Remdesivir, Anakinra

Cultures:  Blood cultures – negative

Antigens:  Legionella Urine Ag negative

Day 0 – Admission Chest Xray

Day 2: HFNC 50L/100%,  BIPAP QHS; Transferred to ICU;  iEPO

Day 7: Endotracheal intubation;  Prone ventilation

Trans Thoracic Echo (TTE): EF 55% – 60%;  Doppler US: no lower limb DVTs

CTA Chest: B/L extensive ground glass opacities and confluent consolidation, 

No PE.

Medication Added:  Vancomycin, Cefepime

Cultures:  Blood cultures – 2/4 bottles S. epidermidis

T2 Candida – negative

Tracheal Aspirate- Negative

Day 7: CTA Chest w/ and w/o contrast  

Day 10: Blood Cultures – negative;   T2 Candida- Negative

Day 11: Cannulated for VV ECMO;  CT Head: B/L SAH;  Bronchoscopy

Cultures: BAL- CMV, HSV, Legionellaa, Fungal and Bacterial cultures all negative

BAL HSV PCR negative; Viral respiratory panel Negative; AsperGal- negative; Beta D glucan- negative

Day 19: Tracheostomy/PEG; Dual oxygenators; Melena

EGD: oozing hyperplastic polyp, resected and clipped

Bronchoscopy:  RLL bleed;  CRRT (Continuous renal replacement therapy)

Cefepime, Vancomycin continued

Day 20: COVID-19 IgG – positive

Day 24: P/F ratio: 99 (normal is >400);  NO started  

CT Chest: Diffuse bilateral consolidation with moderate bilateral pleural effusions

CT Abdomen/pelvis: no abnormalities

Added Pip/tazo

Day 22, 26, 29- BAL Legionella, Fungal and bacterial culture negative

Day 28: Cardioversion for atrial fibrillation;  TTE: Dilated RV, EF 55-60%

Medications added:  Norepinephrine, Vasopression, Epinephrine, Amiodarone, Meropenem and Vancomycin continues

Day 31: Lactic acidosis, increased vasopressor requirements; Leukocytosis.  


Blood culture and T2 Candida negative

Dual Oxygenators

Melena;  EGD: oozing hyperplastic polyp, resected and clipped

Bronchoscopy: RLL Bleed;  CRRT

Day 24- Chest CT  w/o contrast

Day 32: Isavuconazole started

Day 34: Serum AsperGal – positive;  BD Glucan – positive

Isavuconazole continued

Day 44: CT Chest- interval improvement of bilateral consolidations

Day 63: Repeat GI Bleed,  increased vasopressor requirements

CT Chest- Increasing bilateral effusions and worsening right upper lobe  opacification

Day 80: CT Chest: unchanged consolidations,  Digital ischemia;  TA + PsA  

Day 83: Withdrawal of care, deceased.

Day 44-  CT Chest w/o contrast – patchy consolidation in both lungs with areas of dense infiltrates

Day 80-  CT Chest w/o contrast – Progressive dense, bilateral consolidation throughout both lungs