B72-46 Candida in the Blood, Aspergillus in the Lungs: A Chronologic Case of Dual Invasive Fungal Disease

Abstract Introduction Aspergillosis usually presents with fever, increased sputum production, hemoptysis and pleuritic chest pain. Here we present a case of subacute invasive aspergillosis masked by candidal fungemia. Case Presentation A 64-year-old female with a past medical history of schizoaffective disorder, chronic pancreatitis, and a 20-year smoking history presented to our hospital with bilateral lobar pulmonary artery embolisms, she was treated medically and was found to have candidal fungemia which was treated with micafungin. She returned three months later with complaints of night sweats and was found to have a 6.5 cm cavitated right upper lobe lesion on a computed tomography (CT) scan. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) which was negative for acid-fast organisms or malignancy. Fungal cultures were once again positive for candida and micafungin was started. She returned eight months later with altered mental status and extrapyramidal symptoms which resolved gradually over the next few days and were likely secondary to polypharmacy. On admission, chest radiography revealed a new left upper lobe coin lesion. Repeat chest CT was performed which revealed a resolving right upper lobe cavity and a new spiculated mass in the left upper lobe. Robotic bronchoscopy was performed which revealed subclinical hemoptysis and biopsies were obtained. Results showed necrotizing granulomatous inflammation with Grocott’s Methenamine Silver (GMS) and Periodic Acid Schiff for Fungus (PASF) staining positive for Aspergillus and the presence of calcium oxalate crystals which confirmed the diagnosis of subacute invasive aspergillosis. Our patient was treated with micafungin for 2 weeks and then discharged on 12 weeks of voriconazole treatment. Our patient was advised to a repeat CT scan in three months to ensure resolution. Discussion The diagnosis of aspergillosis is difficult even with BAL or a biopsy due to low diagnostic yield. Our patient had multiple cultures throughout her admissions which were all negative for Aspergillus. While pooled blood was found in the left main bronchus, there were no overt signs suggestive of hemoptysis. Radiographic findings further complicate the diagnosis due to the resemblance of an Aspergillus nodule which usually occurs in a pre-existing cavity. In our case, the biopsy revealed necrotizing inflammation confirming subacute invasive aspergillosis. The spiculated appearance on imaging also raises high suspicion for malignancy in a patient with a longstanding history of cigarette smoking. This case highlights the diagnostic difficulty in a patient with subacute invasive aspergillosis with a wide differential including malignancy and tuberculosis. This abstract is funded by: None