Multi-triazole-resistant Aspergillus fumigatus and SARS-CoV-2 co-infection: A lethal combination

Abstract

We report a case of severe COVID-19 pneumonia complicated by fatal co-infection with a multi-triazole resistant Aspergillus fumigatus and highlight the importance of recognising the significance of Aspergillus sp. isolation from respiratory samples. Early diagnosis and detection of triazole resistance are essential for appropriate antifungal therapy to improve outcome in patients with coronavirus associated invasive aspergillosis.

Keywords: COVID-19 pneumonia; Invasive pulmonary aspergillosis; Multi-triazole resistance.

Fig. 1

A. Portable chest radiograph taken on day of admission showing unilateral peripheral left basal airspace shadowing. B. Portable chest radiograph taken on Day 12 of hospitalization (Day 20 of COVID-19 infection). The endotracheal tube and bilateral central lines are in satisfactory position. There has been interval progression of the left peripheral airspace shadowing with additional right upper and lower zone peripheral airspace shadowing with no evidence of cavitation.

Fig. 2

A and B VIPcheck™ plate, a four well triazole resistance screen plate which contains itraconazole (I) 4 mg per liter, voriconazole (V) 2 mg per liter, posaconazole. (P) 0.5 mg per liter, and growth control (GC). This is a simple phenotypic test used to screen for triazole resistance due to the common mutations in the cyp51A gene in A. fumigatus from an environmental source. The photos show a susceptible control strain AF293 (2A) where growth is only seen on GC well and the patient's isolate (2B) with growth in all wells consistent with findings seen in A. fumigatus with the cyp51A TR_34/L98H mutation.