The document reports a clinical case of a 41-year-old male with chronic alcoholism who was initially suspected of having pancreatitis but later diagnosed with invasive pleuropulmonary aspergillosis after further examinations revealed a significant pleural effusion and positive fungal cultures. The patient's condition deteriorated despite treatment with voriconazole, leading to a regimen that included liposomal amphotericin B and capsofungin, resulting in clinical improvement and significant radiological resolution. Key takeaways highlight the atypical presentation of empyema, the role of combined antifungal therapy, and the challenges of diagnosis in immunocompetent patients.

1. D R K A M A L B H A R A T H I . S
P O S T G R A D U A T E
D E P A R T M E N T O F P U L M O N A R Y M E D I C I N E
S R I M A N A K U L A V I N A Y A G A R M E D I C A L C O L L E G E & H O S P I T A L
P U D U C H E R R Y
CLINICAL GRAND
ROUNDS

2. CASE REPORT
 41 year old male, Chronic alcoholic
 Came to our casualty with C/O epigastric pain for
past 5 days.
 Not a known hypertensive, diabetic, asthma or TB
 Initially admitted at surgical unit with clinical
suspicion of pancreatitis.
 USG abdomen- pancreas with mild echogenic and
thin rim of peri-pancreatic fluid.

3. LABORATORY DATA
Hemoglobin 15.7gm/dl
Total Leukocyte
Count
22,700 cells/cm
Neutrophils 88%
Platelet count 3.48 lakhs/cm
Urea 21mg/dl
Creatinine 1.2mg/dl
Total bilirubin 1.0 mg/dl
Direct Bilirubin 0.2 mg/dl
SGOT 30 U/L
SGPT 44 U/L
Sr Albumin 2.9 g/dl
Sodium 135 mmol/L
Potassium 3.4 mmol/L
Chloride 101 mmol/L
Calcium 7.7 mg/dl
Serum lipase 45 U/L (N)
HIV Non reactive
HBsAg Non reactive
HCV Non reactive
Serum amylase 13 U/L (N)

4. INVESTIGATIONS
 ECG: sinus tachycardia
 Cardiac enzymes:
Negative

5. CLINICAL HISTORY
 Pulmonology opinion was obtained on the next day
of admission.
 Patient also gave history of left sided chest pain
which increased on deep inspiration for past 5 days.
 C/O of non-productive cough and dyspnoea for the
past 2 days.

6. PHYSICAL EXAM
 On examination- conscious, alert and tachypnoic
using accessory muscles of respiration.
 Vitals: PR- 112/min; BP- 136/90 mmHg; RR- 38
breath/min; SpO2- 94 %@room air
 On palpation revealed intercostal tenderness over
left infra-axillary area.
 Reduced vesicular breath sounds in the left side
infra-axillary and mammary area.
 Patient was transferred to RICU for non invasive
ventilation.

7. CXR

8. THORACOCENTESIS
 Screening USG thorax- gross
collection in left pleural space
with multiple internal echoes
suggestive of empyema.
 Diagnostic tapping was done
showing pus which was sent
for gram stain, culture, AFB
and fungal smear.
 ICD was inserted and drained
around 1700ml of frank pus.

9. PROVISIONAL DIAGNOSIS
 Post ICD insertion, patient’s tachypnea got settled
down.
 Patient was planned for CT thorax but postponed as
the patient was in Respiratory Failure.
 With working diagnosis of left empyema/ sepsis/
impending ARDS, Patient was started on
clindamycin in addition to piperacillin+ tazobactam
and continued on NIV support.

10. REPORTS
Pleural fluid (Pus)
 Gram stain: no evidence of bacteria
 Culture: no growth
 AFB: Smear negative for AFB
 Fungal smear: few septate branching fungal elements seen.
 CBNAAT: MTB not detected
Sputum
 Gram stain: few gram +ve cocci in short chains
 Culture: throat commensals
 Fungal smear: few septate branching fungal elements seen.
 Fungal culture: negative for fungus
 CBNAAT: MTB not detected

11. WORK UP
 Bedside bronchoscopy was
performed with NIV support
which showed brownish
mucopurulent secretions almost
in all segmental bronchus.
 Transbronchial lung biopsy was
planned it was abandoned as the
patient couldn’t tolerate the
procedure.
 BAL fungal smear and culture
was also sent.

12. CULTURE
 Microbiologist was insisted and asked to review again on
the fungal smear and found few septate acute angled
branching fungal mycelium.
 Fungal culture (Pus):Aspergillus species.

13. FINAL DIAGNOSIS
Invasive Pleuro-Pulmonary
Aspergillosis with ARDS

14. HOSPITAL COURSE
 Started on Injection Voriconazole 6mg/kg on day 1
twice daily followed by 4mg/kg on subsequent days
with other supportive measures.
 Patient was not showing any clinical response and
rapid worsening with hypoxemia.
 Urine and blood culture and sensitivity : No growth
Serum IgM 91 mg/dl (N)
Serum IgG 1251 mg/dl (N)
Serum IgA 103 mg/dl (N)
Serum Procalcitonin 0.57 mcg/L

15. After 72 hrs of voriconazole

16. HOSPITAL COURSE
 As there was clinical worsening and new rapidly
progressive infiltrates on right lung, liposomal
amphotercin B (4mg/kg) was added along with
voriconazole.
 Suspecting secondary bacterial infection antibiotics
were escalated to Inj. Imipenam and Inj.
clindamycin.
 Patient was planned for elective intubation, but
patient attenders were not willing and continued
with continous NIV support.

17. HOSPITAL COURSE
 After starting liposomal amphotericin B, patient
showed partial clinical response so continued with
intermittent NIV.
 Potassium infusion was given to correct hypokalemia
regularly.
 Patient was shifted for CT thorax with oxygen
support.

18. CT Thorax

19. WORK UP
 CTVS opinion obtained and adviced for surgery and
planned for lobar resection but the patient was not
willing to undergo surgery.

20. WORK UP
 Patient was not responding to voriconazole and no
major commercial laboratories are running fungal
culture sensitivity.
 Patient was complaining of blurred vision and
headache for which ophthalmologist opinion was
obtained and suggested that it was because of
voriconazole induced transient visual disturbance.
So, voriconazole was stopped.

21. HOPITAL COURSE
 Hence, Inj. Capsofungin was started along with
liposomal amphotericin B.
 After 3 days of treatment with Capsofungin 50mg
and liposomal amphotericin combination, patient
had shown good clinical response.
 Patient shifted to ward after a week.

22. FOLLOW UP
 Patient symptomatically improved with significant
radiological resolution.

23. COURSE OF STAY

24. FOLLOW UP CT THORAX

25. Take Home Message
Atypical presentation of epigastric pain which mimicked a
pancreatitis initially.
Empyema – though rare still it can be fungal !!!
Suspected to have mixed bacterial infection and treated and
later came out as pleuropulmonary aspergillosis.
As diagnostic yield of sputum shows low sensitivity, NIV
facilitated fibreoptic bronchoscopy was done which showed
positive culture.
BAL galactomannan assay aids in diagnosis with 90%
sensitivity and performed better compared to PCR and
serum galactomannan.

26. Take Home Message
Voriconazole is the preferred drug for first line therapy
for which patient has not shown any clinical response
hence combination therapy was considered.
Combination therapy has shown additive or synergistic
effects and in our case a good clinical as well as
radiological resolution was seen.
Invasive pulmonary apergillosis is more common in
immunocompromised patients, but our patient is
immunocompetent except the history of alcoholism.
As patient was not willing for elective intubation,
patient was continued with NIV support and weaned
off successfully with treatment.

27. Thank You