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).