Discussion
The COVID-19 disease caused by the coronavirus has a broad spectrum of
features, in the severe form causing acute respiratory distress syndrome
(ARDS) (1). The previous influenza pandemic described co-infections and
superinfections of viral, bacterial, and fungal infections (13). In the
current pandemic of COVID-19, in the studies from China (7, 8),
aspergillosis was isolated from the patient’s respiratory tract. Also,
in case series from other regions in the world, there were reports of
CAPA in about 20-35% of mechanically ventilated patients (9-12). Since
there are similarities between Influenza and COVID-19 clinical features,
we expect a similar rate of aspergillus infection in COVID-19 patients.
Nevertheless, aspergillus infection in COVID-19 patients is uncommon
(14). In these patients, aspergillosis infection was mainly associated
with tracheobronchitis, prior lung disease, prolonged mechanical
ventilation, and high immunosuppressor doses or diabetes (14). The
corticosteroid uses in treating COVID-19 disease may increase the risk
of aspergillus infection. The diagnosis of invasive pulmonary
aspergillosis (IPA), according to the European Organization for Research
and Treatment of Cancer/Mycosis Study Group (EORTC/MSG), is categorized
into proven, probable, and possible. When a combination of host
characteristics, clinical manifestations, and positive mycology leads to
proven invasive aspergillosis.
Moreover, possible IPA is considered when there are clinical features
and host factors but negative mycology results (15). The modified
definition of invasive pulmonary aspergillosis (AspICU criteria)
developed lately and is based on positive results of BAL culture,
positive BAL, or serum galactomannan in the absence of histopathology.
The radiologic criteria include any pulmonary infiltration rather than
EORT radiologic criteria (e.g., halo sign or air-crescent sign) because
this criterion is applied more for neutropenic patients (16). Chen L et
al. indicated that the immunocompetent patients with IPA who were
hospitalized with influenza showed a significant correlation between
using corticosteroids before diagnosis and acquiring IPA (17). In the
study evaluating reported cases of CAPA in the ICU, steroid exposure,
diabetes, and chronic lung disease were the more frequent risk factors.
Moreover, pulmonary nodules and cavitary/halo-sign were the dominant
radiologic findings of the IPA patient (18). CNS aspergillosis occurs
mainly in immunocompromised patients with advanced conditions. CNS
aspergillosis may occur in immunocompetent patients and have a different
clinical course and prognosis than immunocompromised patients (19).
Hematogenous spread of aspergillus can involve all parts of the CNS,
including the anterior and middle branches of the cerebral artery, which
can be infiltrated by the hyphae leading to direct and indirect damage,
especially in frontal, temporal, and parietal lobes (20). In a study
evaluating CNS aspergillosis in immunocompetent patients, the frequent
etiologies of CNS involvement were nasosinusitis, diabetes, and
craniotomy. Cerebral infarction occurred in 26.1% of the patients, with
meningeal participation (21). In this report, we present a patient
admitted to our hospital for a neurologic complaint of hemiparesis,
without any known underlying disease, including immunodeficiency, except
for recent glucocorticoid consumption for COVID-19 disease treatment for
five days. We assumed that the neurologic involvement was due to the
patient’s pulmonary aspergillosis infection. Furthermore, the early
starting of the treatment in response to our suspicion of IPA may
improve this patient’s outcome compared to similar case studies
discussed in this paper (17, 21).