Case presentation
A 68-year-old diabetic man was presented to the emergency department with a five days history of fever (38.7 °C), dry cough, and dyspnea (SpO2 was 90% - room air). He was on oral hypoglycemic agent (metformin 500 mg every 12 hours) for several years. Laboratory studies showed elevated C reactive protein (120 mg/dl), and RT-PCR confirmed SARS-COV-2 diagnosis. High-resolution chest CT scan obtained at admission was consistent with COVID-19 pneumonia. The patient received remdesivir and dexamethasone and was discharged after 9 days with improvement of signs and symptoms. After 12 days the patient was re-admitted because of severe dyspnea and fever. Chest CT scan revealed left sided pleural effusion and the chest tube was inserted and discharged after seven days with improvement of dyspnea. After 10 days the patient was referred to our center for the first time, because of malaise, fever, chills and purulent discharge at previous chest tube excite site.
At admission the patient was febrile and the vital signs were as following: PR: 110 beats/min, RR: 25 breath/min T: 38.5 and BP: 120/90 mmHg. The initial laboratory data were as following: white blood cell count (WBC): 4900/mm3 (neutrophils: 83%, lymphocytes: 8%), hemoglobin (Hb): 10.2 gr/dl, platelets (PLT): 250,000/mm3, blood sugar: 187 and creatinine: 1.1 mg/dl. Also COVID-19 PCR was reported positive. Pleural fluid was sent for analysis, bacterial and fungal smear and culture. Blood cultures were negative. The pleural fluid analysis were as following: turbid appearance, white blood cell >500,000, polymorphonuclear 90%, lactate dehydrogenase (LDH) 26,448 U/L, sugar <10 mg/dl, protein 2.9 gr/dl, albumin 1.9 gr/dl. Serum LDH level, total protein and albumin were 523 U/L, 5.1 gr/dl and 3.2 gr/dl respectively, indicative of empyema and chest tube was inserted.
Imipenem 500 mg every 6 hours and vancomycin 1 gr every 12 hours were started as empiric treatment. The result of culture was reportedklebsiella pneumoniae which was sensitive to meropenem and also imipenem. The vancomycin was discontinued and imipenem with amikacin was continued. The patient presented extensive subcutaneous emphysema in both sides and left chest tube was inserted (Figure 1). After several days the left sided chest tube was came out. According to the right sided empyema and no significant improvement, the patient underwent right thoracotomy with decortication. In addition, right upper lobe and right lower lobe wedge resection, hilar lymph node biopsy and partial pleural peel resection was performed. After the operation, the whole lung was expanded and an anterior and posterior chest tube was implanted for the patient.
In histopathology right upper lobe wedge resection, revealed severe suppurative necroinflammatory process associated with presence of a few partially degenerated fungal hyphae (both wide and irregular). Right lower lobe wedge resection showed extensive severe suppurative necroinflammatory process associated with presence of numerous fungal hyphae (both wide and irregular). Also vessel wall infiltrated by several fungal hyphae including both thin and broad fungal hyphae and calcium oxalate crystals accompanied by fungal hyphae was indicative of aspergillosis (Figure 2).
Hilar lymph node, biopsy revealed fibro-inflammatory process including foci of anthracotic pigment deposition. Fibro-adipose tissue showed bland looking gland like structures, patchy lymphocytic infiltration and presence of few large cells with cytopathology suggestive of CMV infection. Immunohistochemistry (IHC) was performed and confirmed the diagnosis of CMV pneumonia (Figure 3).
According to the invasive fungal infection with both Aspergillusand Mucoraceae species and also with the diagnosis of CMV disease, the liposomal amphotericin B, 5 mg/kg/day and intravenous gancyclovir 5 mg/kg every 12 hours were initiated. Also the imipenem with amikacin was continued for Klebsiella pneumoniae empyema. The patient signs and symptoms were improved and was afebrile. After discontinuation of amphotericin B and intravenous gancyclovir course, posaconazole oral suspension 200 mg every 6 hours and valgancyclovir 900 mg every 12 hours was started. The patient was discharged after one month with favorable clinical outcome.