Pseudomembranous Aspergillus tracheobronchitis with secondary Acinetobacter baumannii pneumonia

A 69 yr old male† was admitted to the intensive care unit of Employee's State Insurance Corporation-Postgraduate Institute of Medical Sciences & Research (ESI-PGIMSR), New Delhi, India, on June 2019, with acute respiratory failure. He was an ex-smoker and presented with complaints of cough and breathlessness since three years. There was increased cough, purulent sputum and fever since four days. He had well-controlled diabetes and ischemic heart disease since five years. He also gave a history of pulmonary tuberculosis six years back. Imaging studies showed bilateral patchy consolidation with cavitation (Fig. 1A-C). Sputum investigations were negative for tuberculosis and culture showed growth of Acinetobacter baumannii and Aspergillus fumigatus. The patient was given antibiotic treatment as per the sensitivity reports. Bronchoscopy performed showed multiple greyish white nodules (pseudomembranes) studded throughout the tracheobronchial tree which were adherent to the mucosal wall (Fig. 2A). Biopsy from the nodules were cultured which showed growth of A. fumigatus (Fig. 3). Bronchial washings also yielded A. baumannii and A. fumigatus. The diagnosis was confirmed to be pseudomembranous Aspergillus tracheobronchitis with pneumonia due to A. baumannii. Treatment with voriconazole for three months and appropriate antibiotics showed significant resolution of the lesions (Figs 2B and 4A-C).

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Fig. 1 (A) The chest radiograph at presentation, showing bilateral patchy consolidation. (B and C) represent the computed tomography scan in lung window showing bilateral consolidation with some cavitation. (B) Also showed a hazy opacity (arrow) within the tracheal lumen suggestive of pseudomembrane.

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Fig. 2 (A) Represents the bronchoscopic images at various levels of the tracheobronchial tree showing multiple greyish white nodules adherent to the mucosal wall. (B) Significant resolution of the lesions on follow up bronchoscopy after treatment with voriconazole.

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Fig. 3 The microscopic image obtained on lactophenol cotton blue stain of slide culture preparation showing hyphae and conidial heads of Aspergillus fumigatus (×10).

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Fig. 4 (A) The chest radiograph and represent the computed tomography scan images and (B and C) in lung window after treatment showing resolution of the lung lesions and endotracheal pseudomembranes.

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