View Abstract

A5403 - Aspergillus Empyema in a 70 Year Old Male Recently Started on Dexamethasone
Author Block: D. See; University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
Invasive fungal infections are common in hematological malignancy, hematopoetic stem cell and solid organ transplant, and Human Immunodeficiency Virus (HIV) patients. Even in these immunocompromised populations, anti-fungal prophylaxis is targeted only at a subset of high risk cancer patients. Long term high dose systemic steroids are known to suppress the immune system placing patients at higher risk for opportunistic infections. For patients on chronic steroids, the only guideline based recommendation for anti-microbial prophylaxis is for pneumocystis jirovecii. While pneumocystis prophylaxis is established, current guidelines do not recommend prophylaxis against aspergillosis, the most common mold infection worldwide. Invasive disease is usually life threatening and associated with neutropenia, steroid use or chemotherapy.
This is a case of a 70 year old male with a history of coronary artery disease with congestive heart failure and multiple sclerosis on glaterimer acetate injections who presented with mechanical fall complicated by cervical spine fracture and spinal cord impingement. He underwent cervical fusion and was started on dexamethasone 4 mg every 6 hours. Thirteen days later he presented to an emergency department with cough, leukocytosis, and right-sided infiltrate with associated pleural effusion on chest x-ray. He did not improve on broad spectrum antibiotics and so underwent thoracentesis which revealed exudative, neutrophilic pleural fluid: Initial microscopy revealed septate hyphae that speciated to aspergillus fumigatus. His HIV antibody test returned non-reactive. Despite antifungals and chest tube placement, the patient continued to have a high oxygen requirement, so he underwent video-assisted thorascopic surgery with wash out and found to have a necrotic lingula that was intra-operatively resected. Surgical lung biopsy revealed necrotic lung and hyphae.
Invasive fungal disease such as fungal empyema is rare in immunocompetent patients. This patient did not possess classic risk factors for invasive fungal disease. However, he was recently post-op and started on dexamethasone which may be have been contributing risk factors for development of such an infection. I propose investigation for development of risk stratification for fungal infections in non-malignant, transplant or HIV patients that would include items such as age, gender, steroid use dosage and duration, recent surgery status including surgery location and or type, and other medical comorbidities. This risk assessment may be helpful in identifying additional patient populations who may benefit from anti-fungal prophylaxis.