Introduction
Since December 2019, an outbreak of coronavirus pneumonia caused by SARS-COV-2 started in Wuhan, China (1) and later spread worldwide. Severe viral pneumonia-causing hospitalization and respiratory failure is an essential feature of this disease (2). Invasive Aspergillosis infections have been reported in severe respiratory syndrome-coronavirus (SARS-CoV) in 2003 and Middle East Respiratory Syndrome-coronavirus (3, 4). In critically ill patients of influenza, the Influenza-associated pulmonary Aspergillosis (IAPA) is a risk factor for morbidity (5, 6). Several studies from Wuhan (7, 8), Belgium (9), France (10), Netherland (11), and Germany (12) have reported COVID-19 associated pulmonary Aspergillosis (CAPA) in critically ill patients and mainly on mechanical ventilation. Corticosteroid use in the treatment of Covid-19 patients may contribute to CAPA risk. This report presents a young man with neurologic presentation and cavitary lung lesions with a history of recent hospitalization for moderate Covid-19 pneumonia.
Clinical case
A thirty years old male was admitted to the emergency room with a chief complaint of hypoesthesia in both lower limbs, right hand, and dysarthria since the day before. He had no history of loss of consciousness or head trauma, diplopia, dysphagia, facial weakness, fecal or urinary incontinence, dysarthria, nausea or vomiting, articular pain or swelling, oral ulcer, photosensitivity nasal discharge. However, he was complaining of headaches, fever, and vertigo. The patient also mentioned exertional dyspnea since getting infected with Covid-19, which led to hospitalization 20 days ago. The patient’s past medical history had no significant reporting except for the recent admission for Covid-19 infection, which was treated with Remdesivir and Dexamethasone for five days in another healthcare center. His habitual history was positive for hookah, but no further history of smoking or alcohol use was mentioned. There were construction works in the patient’s neighborhood recently. He noted that his mother has a history of hypertension. The patient’s signs improved since their onset but did not resolve completely. In the physical examination, the patient was slightly ill but had no respiratory distress; blood pressure was 110/80 mmHg, the pulse rate: was 80 b/min, respiratory rate of 18/min, the temperature of 36.8 ^c, and O2 saturation: was 96%.
Moreover, muscle forces and the other neurologic examinations were normal. Lung and brain CT scans were done and had no obvious abnormality. Brain MRI was performed, and there was an abnormal signal intensity in the left frontal region in T2/FLAIR, which indicates a restriction in Diffusion-Weighted Imaging (DWI) in favor of acute infarction in the left middle cerebral artery (MCA) territory (figure 1). The bilateral carotid Doppler ultrasound revealed low resistance arterial flow without evidence of significant narrowing or dissection. Initial lab data is shown in Table 1.
Neurologic consult recommended treatment with Aspirin (80 mg oral intake daily), Clopidogrel (75 mg oral intake daily), and Atorvastatin (20 mg oral intake daily). On the day after admission, the patient had dyspnea, and the level of O2 saturation dropped to 77% with rose to 95% with oxygen therapy, and he developed tachycardia (PR=120b/min). Lung CT angiography to rule out pulmonary thromboembolism (PTE) was performed. There was no evidence of thrombosis in the main and segmental branches of the pulmonary artery. There was evidence of previous Covid-19 infection in lung parenchyma and nodular opacities with some cavitation suggesting superimposed infections or possibly due to septic emboli (figure 2). Broad-spectrum antibiotics were initiated, and blood cultures were sampled. Transthoracic echocardiography (TTE) was done, which had a poor view due to the patient’s obesity and tachypnea; then, Transesophageal echocardiography (TEE) was performed, which reported normal RA size with a moderate, fluffy, network-shaped mobile mass in the Right Atrial (RA); however, the operator could not determine the lesion was a pathologic or not. The other findings were normal and had no evidence of RV strain, vegetation, or significant valve abnormality, and cardiac MRI was suggested for better evaluation. The patient’s exertional dyspnea was aggravated, resulting in immobility; therefore, the patient needed urinary catheterization. For reevaluation, we repeated pulmonary CT angiography. The cavitary lesions progressed in size and distribution with a dominant cavity sized 107, 70, and 50 mm in the superior segment of the left lower lobe with internal fluid level septation, suggesting fungal infections. An infectious disease specialist consults recommended antifungal therapy with intravenous Voriconazole (200mg every 12 hours) was started. Sputum exam for fungal and bacterial infections was negative. Bronchoscopy and Bronchoalveolar lavage were performed, and the smear and culture for alveolar lavage were negative for bacterial and fungal infection. The patient had an episode of hematuria; urine analysis revealed microscopic hematuria without dysmorphic RBC and pyuria.