A 72-year-old male patient, who previously worked as a teacher and cacao farmer, with a previous history of hypertension and ischemic stroke, in addition, the patient had been receiving treatment with botulinic toxin, as a measure to improve facial symmetry, reducing hyperkinesis, and facial imbalance due to the diagnosis of Bell's palsy. This treatment was provided by a private neurologist from another hospital, we were not provided with previous computed tomography (CT) and magnetic resonance imaging (MRI) studies.
The patient presented at the emergency department to the hospital with and 10-day history of fever, respiratory symptoms, productive cough, occasional chest pain, and dyspnea with hypoxemia (SO2 85%). He has previously received 2 doses of COVID-19 vaccine, and real-time polymerase chain reaction (RT-PCR) for SARS-CoV-2 was negative.
Owing to severe dyspnea and persistent hypoxemia despite administration of oxygen, the patient required orotracheal intubation and mechanical ventilation. Laboratory results upon admission were as follow: white blood cells 11.420/microL (normal value [NV]: 4.000-11.000/microL), neutrophils 94% (NV: 40%-60%), lymphocytes 22.4% (NV: 20%-40%), C-reactive protein (CRP) 38 mg/dL (NV: 0-5 mg/dL), procalcitonin 0.23 (NV: 0.25-0.50 mg/dL), ferritin 118 ng/mL (NV: 12-300 ng/mL), and D-dimer 450 ng/mL (NV: < 500 ng/mL). Chest computed tomography (CT) scan showed bilateral consolidation with left predominance (Figure 1).
A diagnosis of severe CAP was made, and empirical antibiotic therapy with cefepime and levofloxacin was started. On hospital day 2, once the patient was hemodynamically stable, fiberoptic bronchoscopy was performed, wherein thick whitish mucous secretions obstructing the bronchial lumen were observed (Figure 2).
The BAL sample was sent to the molecular biology laboratory, and no microorganisms were detected through a FilmArray respiratory panel and MALDI-TOF Biotyper mass spectrometry. In addition, the BAL samples were negative for Ziehl Neelsen (ZN) stain, GeneXpert MTB/RIF (Xpert), and Lowenstein-Jensen culture for tuberculosis.
On hospital day 4, sedation and ventilator weaning were started; however, atelectasis of the left lung was noted (Figure 3). On hospital day 5, a second fiberoptic bronchoscopy was performed, which yielded similar findings of a thick mucus plug obstructing the bronchial lumen of the right and left pulmonary segments and scattered whitish plaques on the bronchial mucosa. Bronchoalveolar lavage was performed once again, and the samples were sent for bacteriological and fungal study. The following results were obtained: Galactomannan Aspergillus test 0.18 pg/mL (negative), mamanocandidas for Candida 166 pg/mL (positive), and KOH smear with fungal structures compatible with yeasts. In addition, MALDI-TOF Biotyper mass spectrometry identified C tropicalis (Figure 4).
Treatment was started with echinocandins, specifically caspofungin 75 mg as an initial dose and then 50 mg daily. Pulmonary biopsy at the level of the carina was taken, and the sample was sent for histopathological study.
By hospital day 7, due to prolonged intubation and failure to wean from the ventilator, surgical tracheostomy was scheduled.
The lung biopsy report revealed the following: surface epithelium had areas of reactive hyperplasia without atypia; the chorion had variable degrees of edema and a discrete quantity of scattered lymphoplasmacytic inflammatory cells, alternating with occasional neutrophils. Few conserved bronchial glands and undamaged paired smooth muscle lamina were also identified.
After 10 days of treatment with caspofungin, ventilatory weaning was finally achieved, without presenting with a new episode of pulmonary atelectasis. By day 14, the patient was decannulated from the tracheostomy. Oral antifungal treatment with voriconazole was continued, and he was discharged from the ICU in good clinical condition.
One month after discharge, a high-resolution CT scan of the chest was performed revealing scarce cylindrical bronchiectasis (Figure 5).