Malignant course of invasive pulmonary aspergillosis in the new coronavirus infection COVID-19

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Abstract

Respiratory infections caused by fungal pathogens are the main cause of death in immunocompromised patients. During the COVID-19 pandemic, the registration of respiratory fungal pathology, especially pulmonary aspergillosis, has increased significantly.

We present a histopathologically confirmed case of fatal invasive pulmonary aspergillosis complicating COVID-19. A 65-year-old patient with long-term diabetes backgrounded with a severe course of COVID-19 (the virus was identified ICD-10 code U07.1) described. During the illness bilateral polysegmental pneumonia of fungal-bacterial (Klebsiella pneumoniae) etiology with necrosis and sequestration of the affected tissue the lower lobe of the right lung with the formation of a “fungal ball” and the development of a right-sided pneumothorax was developed. In other parts of both lungs, focal destruction of the interalveolar septa was determined with the formation of small cavities filled with detritus and accumulations of segmented neutrophils, with the proliferation of fungal mycelium, positively stained in the PAS reaction. Fungal hyphae and conidial heads were also found in the lumens of individual bronchi and vessels with invasion of their walls. Long-term (more than one month) course of the disease, clinical and radiological dynamics, and detection of a forming connective tissue capsule along the periphery of the necrosis zone during microscopy testifies in favor of the subacute nature of the infection.

The presented clinical case, as well as a review of current publications and meta-analyses on invasive pulmonary aspergillosis, point to diagnostic problems and poor outcomes of invasive pulmonary aspergillosis in patients with COVID-19.

Pulmonary aspergillosis associated with COVID-19 is a serious and potentially life ― threatening complication in patients with severe COVID-19 receiving immunosuppressive treatment. Early diagnosis of fungal infections is crucial to ensure the survival of such patients. Targeted biopsy examination with microscopy and/or seeding of a lung biopsy allows not only to establish the diagnosis of aspergillosis, but also to determine the presence of tissue invasion.

Further research should include approaches aimed at developing an effective diagnosis of fungal tissue invasion and respiratory tract damage, determining the patient’s immune status in order to conduct personalized immunotherapy.

About the authors

Marina G. Avdeeva

Kuban State Medical University

Author for correspondence.
Email: avdeevam@mail.ru
ORCID iD: 0000-0002-4979-8768
SPIN-code: 2066-2690

MD, Dr. Sci. (Med.), Professor

Russian Federation, Krasnodar

Natalia V. Mozgaleva

Clinical infectious diseases hospital No. 2

Email: mozgalevanv@ikb2.ru
ORCID iD: 0000-0002-4416-6884
SPIN-code: 5869-2066

MD, Cand. Sci. (Med.)

Russian Federation, Moscow

Yury G. Parkhomenko

Clinical infectious diseases hospital No. 2; Scientific Research Institute of Human Morphology named after academician A.P. Avtsyn

Email: parhomenkoyg@ikb2.ru
ORCID iD: 0000-0001-9857-3402
SPIN-code: 8054-5634

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow; Moscow

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Supplementary files

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2. Fig. 1. Digital radiography of the lungs, direct posterior projection: а ― 9th day of illness, extensive subpleural areas of reduced pneumatization of both lungs with fuzzy contours, medium and low density ― bilateral interstitial pneumonia; b ― 15th day of illness, positive dynamics in the form of a decrease in the intensity of infiltration of the lung tissue over both lung fields; с ― on the 27th day of the disease, on the right in the lower sections, an inhomogeneous area of enlightenment 60×74 mm, with thick walls, is visualized.

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3. Fig. 2. Tumor-like mass in the lower lobe of the right lung. Macropreparation: arrows indicate a cavity filled with dry gray-black masses of spongy appearance.

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4. Fig. 3. Microscopic changes in the lungs (stained with hematoxylin and eosin): а ― intraalveolar edema, hemorrhages, hemorrhagic infarcts, ×50; b ― thickening of the interalveolar septa, proliferation and desquamation of the alveolar epithelium, organizing fibrin in the lumen of the alveoli, ×200; с ― on the surface of the abscess wall containing the cartilaginous tissue of the bronchus (), mycelium of the fungus (indicated by arrows), ×50; d ― detail of the previous one, fragments of the mycelium of the fungus, ×400.

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