Avneep Aggarwal, MD
Attending Physician
Cleveland Clinic, United States
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Title: Invasive Aspergillosis necessitating Clagett thoracotomy: An ICU nightmare
Introduction: Invasive aspergillosis is a major cause of death in immunocompromised patients. We report a case of medically refractory invasive aspergillosis that required surgical debridement with Clagett Window for source control.
Description: 65-year-old female with ulcerative colitis was admitted for gastrointestinal bleeding and fever. Her symptoms persisted despite IV infliximab and high dose steroid therapy. She subsequently underwent total colectomy and end ileostomy. On postoperative day 4, she developed respiratory insufficiency and progressive weakness which prompted admission to surgical ICU. Her chest CT showed left upper lobe complex multi-cavitary lesion consistent with necrotizing fungal pneumonia, and bronchoalveolar lavage grew Aspergillus fumigatus. Further neuroimaging demonstrated a large frontal lobe mature cerebral abscess. Purulent fluid with fungal hyphae was aspirated from the abscess through craniotomy and culture returned positive for the same causative fungal agent, in keeping with invasive aspergillosis. Isavuconazole and Micafungin were initiated. Despite anti-fungal coverage, the patient’s clinical status continued to deteriorate with worsened respiratory distress, hypotension and fever. Repeat chest CT demonstrated progression of the disease with an enlarging left upper lobe abscess. In order to provide optimal source control, Clagett open window thoracotomy was performed for continuous drainage and irrigation. Surgical pathology again revealed numerous septate hyphae positive for Aspergillus Fulmigus. The post-operative course was unremarkable, and her condition continued to improve, she was discharged to long term care facility in stable condition with plan to continue micafungin and isavuconazole for 3 months.
Discussion: Prompt diagnosis, early antifungal coverage is crucial to the effective management of invasive aspergillosis. In addition to anti-fungal therapy, surgical management may be necessary as adjunctive therapy in complex cases with chronic necrotizing disease. Our case illustrates the essential role of surgical management to deride necrotic tissue in cases where a large degree of necrosis limits antifungal activity.