Abstract An uncommon presentation of invasive aspergillosis in a non-classically immunocompromised host, highlighting the importance of early suspicion and prompt management. Invasive pulmonary aspergillosis (IPA) is a life-threatening infection classically linked to immunosuppression such as hematologic malignancy, neutropenia, or solid organ transplantation. Increasing evidence shows IPA can also occur in critically ill patients without these risk factors. Diagnosis is often delayed because clinical findings overlap with bacterial or viral pneumonia, and existing criteria (EORTC/MSGERC)1may not capture this population. Case Presentation A 39-year-old man with treated hepatitis C and active alcohol use disorder presented with one week of confusion and weakness. He denied respiratory symptoms, and chest radiograph on admission was unremarkable. Human immunodeficiency virus testing was negative. On hospital day 2, he developed acute hypoxic respiratory failure requiring intubation; chest imaging showed bilateral infiltrates suggestive of pulmonary edema versus multifocal pneumonia. Broad-spectrum antibiotics and vasopressors for septic shock were initiated. Infectious workup for bacterial and viral pathogens was negative. However, tracheal aspirates obtained shortly after intubation grew Aspergillus fumigatus on two separate cultures, and serum galactomannan was positive. Voriconazole was initiated with marked clinical and radiographic improvement, leading to extubation after 11 days. Follow-up cultures were negative after one month. His course was later complicated by spontaneous bacterial peritonitis, acute kidney injury requiring continuous renal replacement therapy, and reintubation for hemodynamic instability. He developed hospital-acquired pneumonia with vancomycin-resistant Enterococcus faecium and disseminated intravascular coagulation. Despite maximal support, he succumbed to multiorgan failure approximately 50 days after admission, after transitioning to comfort-focused care. Discussion IPA is increasingly recognized among ICU patients without classic immunosuppression. One study found up to 80% of cases occurring in nonhematologic malignancy.2 Patients with liver cirrhosis are particularly vulnerable due to immune dysregulation and impaired phagocytic function. Mortality in IPA associated with liver failure approaches 100%.3 Diagnosis is challenging because standard criteria rely on neutropenia or histopathology, often impractical in critically ill patients.1,4 Conclusion Invasive aspergillosis should be considered in patients with liver cirrhosis or critically ill patients with unexplained respiratory failure, even in the absence of classical risk factors. Early recognition and empiric antifungal therapy based on clinical and microbiologic clues may improve outcomes in this underrecognized and often fatal infection. This case shows a serious, underrecognized infection in an ICU patient where clinical judgment guided prompt treatment in a case not currently recognized as probable or proven invasive aspergillosis by EORTC and MSGERC criteria.1 This abstract is funded by: None
Lemaster et al. (Fri,) studied this question.