Case #2: COVID-19 and Aspergillosis
Submitted by: Ryan Carroll, MD; Peter Pappas, MD
Institution: UAB
Email: ppappas@uabmc.edu
Date: 02/12/2021
History
Chief Complaint: 50-year-old male, shortness of breath, dry cough, fever and worsening hypoxia
| Medical Hx | Surgical Hx. | Family Hx | Social History |
| CML (on imatinib) | Coronary stents | Coronary artery disease | Uses 1 can smokeless tobacco daily |
| Coronary artery disease | Appendectomy | Type II diabetes | Occasional alcohol, denies illicit drug use |
| Hypertension | Cholecystectomy | ||
| Hyperlipidemia | Meniscal repair | ||
| Type II diabetes (A1C 8.3) |
Review of Symptoms:
Present
Shortness of breath
Dry cough
Fever, Chills
Worsening hypoxia
MEDICATIONS – at admission
Aspirin
Clopidogrel
Imatinib
Losartan
Metformin
Omeprazole
Rosuvastatin
PHYSICAL EXAMINATION:
Vital Signs: T 103 F; 39.4 C, HR 94, RR 22, BP 116/62
General: Awake, alert, mild distress
Cardio: RRR, no murmurs, rubs, or gallops.
Pulmonary: Wheezes bilaterally, no rales or crackles
Abdomen: Soft, nontender, bowel sounds present
Musculoskeletal: Strength 5/5 in extremities.
Lymph: No significant lymphadenopathy
Skin: No rashes
Admission Labs
CHEMISTRY/METABOLIC PANEL
Creatinine 1.9 (baseline 1.1)
AST 77
ALT 83
LDH 284
CBC
WBC 4
Other labs
Ferritin 779
COVID-19 PCR positive
Baseline Chest X Ray
Timeline of Hospital Course/Images
Day -5: Respiratory symptoms, fever, COVID-19 positive
Day 0: Admission
Started dexamethasone and remdesivir
Day 2: Worsening hypoxic respiratory failure, intubation
Blood and sputum cultures- negative
Vancomycin, cefepime and azithromycin (Day 1-3), then stopped
Day 5: Persistent fever, worsening respiratory status
Serum Cryptococcus Ag – negative
Urine Histoplasmosis Ag- negative
Urine Blastomycosis Ag- negative
Urine Legionella Ag- negative
Serum AsperGM 0.129 (nl < 0.5)
Day 5 – Chest X-Ray
Day 9: Persistent fever, no improvement in oxygenation
Reinitiated broad-spectrum antimicrobials: vancomycin, piperacillin-tazobactam, and micafungin
Bronchoscopy BAL: Proteus mirabilis (low colony count)
Serum AsperGM repeated (2.278)
Voriconazole initiated
Day 12: Serum AsperGM (0.055)
Improved oxygenation and fevers; extubated on Day 12
Day 14: Serum AsperGM (0.087)
Day 22: Discharged to rehabilitation facility
Continued Voriconazole for 6 weeks as outpatient
Day 84: F/u as outpatient 6 weeks after D/C. No residual cough, shortness of breath or sputum production