Case report: Unveiling the silent threat in the ICU - a case of disseminated invasive aspergillosis in a patient with fulminant myocarditis

Abstract

Invasive aspergillosis (IA) significantly increases mortality in critically ill patients in the ICU and its occurrence is closely related to immunocompromise. Dissemination of IA is easily misdiagnosed and mistreated due to its ability to invade multiple systems throughout the body and lack of typical clinical manifestations. In this case, a 25-year-old previously healthy woman was hospitalized with fulminant myocarditis and treated with veno-arterial extracorporeal membrane pulmonary oxygenation (VA-ECMO) support and intravenous acyclovir, high-dose methylprednisolone, and immunoglobulin. 6 days later, she was successfully weaned from VA-ECMO and underwent cardiac rehabilitation. On day 10, she developed a fever (Tmax 38.3°C) and an irritating cough and began to experience reduced vision over the right eye with eye pain, redness, photophobia, and tearing 2 days later. Administration of levofloxacin eye drops and tobramycin/dexamethasone eye ointment was ineffective. The patient was positive for serum Aspergillus galactomannan antigen. Positron emission tomography/computed tomography (PET/CT) scan showed multiple hypermetabolic cavitary nodules in both lungs (SUVmax3.6) and thickening of the ocular ring wall with hypermetabolism in the right eye (SUVmax3.2). Ophthalmologic examination revealed that her best-corrected visual acuity in the right eye was reduced to light perception with an intraocular pressure of 21 mmHg, and B-scan ultrasonography showed vitreous opacity and retinal edema with mild detachment in the right eye. Metagenomic next-generation sequencing (mNGS) identified a large number of Aspergillus fumigatus sequences in bronchoalveolar lavage fluid, blood, and aqueous humor from the right eye, supporting the diagnosis of pulmonary and ocular involvement due to disseminated IA. Vitrectomy, anterior chamber irrigation, combined with intravenous and intravitreal injections of voriconazole and liposomal amphotericin B eventually cured the patient. This case highlights the importance of early identification and intervention regarding disseminated IA in immunocompromised critically ill patients, especially in the presence of multiple organ involvement.

Keywords: PET/CT; disseminated infection; immunocompromise; invasive aspergillosis; mNGS.

Figure 1

Ocular appearance and PET/CT scan of the chest. (A) Clinical photograph of the patient on day 13 after admission, showing conjunctival congestion in the right eye with pus in the anterior chamber (red arrow). (B–D) Axial chest CT (B1–B5), PET (C1–C5), and fusion PET/CT (D1–D5) images showed the presence of multiple cavitary nodules in both lungs with increased FDG uptake (red crosses).

Figure 2

PET/CT scan of the orbit. (A–C) Axial orbital CT (A), PET (B), and fusion PET/CT (C) images showed thickening of the ocular ring wall with increased FDG uptake in the right eye (red arrows).

Figure 3

Ocular B-scan ultrasonography and culture of right aqueous humor before treatment. (A) B-scan ultrasonography images (A1–A3) of the right eye showed vitreous opacity and retinal edema with mild detachment. (B) B-scan ultrasonography (B1–B3) of the left eye revealed no abnormalities. (C) Potato dextrose agar medium showing the colonies of A. fumigatus. (D) Microscopic examination showing typical A. fumigatus morphology including branching hyphae and granular spores (Lactophenol cotton blue staining, 1000×).

Figure 4

B-scan ultrasonography of the right eye and chest CT scan after treatment and timeline of the hospitalization process. (A) B-scan ultrasonography of the right eye on day 28 (A1–A3) revealed a significant reduction in vitreous opacity, while the retina remained edematous with mild detachment. (B) Chest CT scan on day 60 (B1–B5) showed significant absorption of Aspergillus lesions in both lungs (red arrows). (C) The timeline and treatment course for the patient.