Sany Kumar, MD,
Fellow
Memorial Sloan Kettering Cancer Center
New York, NY
Disclosure information not submitted.
Padmastuti Akella, MD
Critical Care Physician
USF/TGH/Moffitt Cancer Center, United States
Disclosure information not submitted.
Saira Imran, MD
Staff Physician
Memorial Sloan Kettering Cancer Center, United States
Disclosure information not submitted.
Stephen Pastores, MD, MACP, FCCP
Program Director, Critical Care Medicine
Memorial Sloan Kettering Cancer Center
New York, NY, United States
Disclosure information not submitted.
Neeta Kumari, MBBS
Medical Staff
Public Health School, United States
Disclosure information not submitted.
Abhishek Dutta, MD
Fellow
Memorial Sloan Kettering Cancer Center
New York, New York, United States
Disclosure information not submitted.
Title: Pseudomembranous tracheobronchitis secondary to aspergillosis: A diagnostic challenge
Introduction: Pseudomembranous tracheobronchitis (PMTB) is an infrequent manifestation of Aspergillus infection. The diagnosis of PMTB is complex, and the disease is uniformly fatal if not recognized early. Herein, we present a case of PMTB in a patient with multiple myeloma who developed rapid clinical deterioration.
Description: A 68-year-old male with a history of relapsed multiple myeloma underwent multiple lines of therapy followed by an autologous hematopoietic stem cell transplant presented with fever, shortness of breath, and diarrhea. Vital signs were significant for a temperature of 38.1*C and sinus tachycardia (HR 130/min). Laboratory workup was remarkable for absolute neutropenia ( < 0.1). Chest CT showed bilateral multifocal patchy opacities. He was treated with broad-spectrum antibiotics and fluconazole. During hospitalization, he had increased oxygen requirements and was intubated and admitted to the ICU. His infectious disease workup was remarkable for an elevated beta-D glucan >500 and positive Aspergillus galactomannan antigen. Bronchoscopy revealed bilateral thick white mucus plaques with an obstructive pseudomembranous pattern along the tracheobronchial tree, most prominent in the right main bronchus. Bronchial washing was positive for Aspergillus fumigatus. His course was further complicated by multiorgan failure. Fluconazole was replaced by isavuconazole. The patient's clinical condition deteriorated, and the family decided not to pursue further aggressive measures and died after palliative extubation.
Discussion: Aspergillus tracheobronchitis is an uncommon manifestation of invasive pulmonary aspergillosis and accounts for < 10% of cases. Diagnosis of PMTB due to Aspergillus is often delayed due to the nonspecific presentation and the lack of specific radiographic findings in the early stages. The various findings described on bronchoscopy include pseudomembranous, obstructive, ulcerative, and obstructive tracheobronchitis. The pseudomembranous form is the most common (32%) and is more frequently found in neutropenic patients. Respiratory failure in PMTB may result from the pseudomembranes constricting the airways and its dislodgement, thus creating a ball valve leading to obstruction. The outcome of antifungal therapy depends mainly on the patient's immune status.