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.