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.