Case #1: COVID-19 and Pulmonary Aspergillus 

 Submitted by: Elizabeth Thottacherry, Peter Pappas 

Institution: UAB 


Date: 2/12/21 


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

Medical HxFamily Hx Social Hx:Surgical Hx 
Coronary artery diseaseFather- Renal Cancer Denies substance abuse, smokingPercutaneous coronary intervention 
HypertensionRare alcohol, no history of binge drinking Knee Surgery 
Chronic back pain
Overweight (BMI 27 kg/m2)


PresentNot Present 
DiaphoresisSore Throat
Body AchesRhinorrhea

MEDICATIONS – at admission 

Aspirin 81mg PO daily 

Clopidogrel 75mg PO daily 

Dexlansoprazole 30 mg PO daily 

Lisinopril/Hydrochlorothiazide 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 mm/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 

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, Legionella, 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); iNO 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, Vasopressin, 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