A 19-year-old woman who worked as a laundress in a river presented to a primary health care facility 72 hours prior to admission, after giving birth by vaginal delivery. Her main complaints were transvaginal bleeding and persistent fever. In the primary health facility, the doctors performed a uterine aspiration, and 48 hours after the procedure, as the patient continued with the same symptomatology, she was referred to our hospital.
On examination, the patient presented fever, tachycardia, tachypnea, use of accessory breathing muscles, and oxygen saturation of 80%. Laboratory results showed slightly low hemoglobin of 11.1 g/dL and hematocrit 32.9% with elevated leukocyte count of 19 900 mm3 and a normal platelet count of 350 000 mm3, glucose 79 g/dL, serum sodium 138 mEq/L, potassium 2.5 mEq/L, chlorine 108 mEq/L, urea 5, and creatinine 0.9 g/dL. A pelvic abdominal CT scan evidenced a uterus with hyperdense areas outside the pelvic cavity.
The patient was diagnosed with puerperal sepsis and a partial hysterectomy was performed. After the procedure, the patient was transferred to the intensive care unit where she remained with invasive mechanical ventilation on intermittent positive pressure ventilation mode; sedation and analgesia with propofol 1 mg/kg/h and fentanyl 1 microg/kg/h, respectively, and vasopressors with norepinephrine 0.1 to 0.2 microg/kg/min, for 3 days. Intravenous antibiotics were administered and included meropenem 2 g every 8 hours and vancomycin 1 g every 12 hours. Additionally, the patient presented vaginal mycosis, so fluconazole was introduced.
Chest X-ray and CT evidenced a nodular pattern and infiltrates in both lungs, and by the third day of admission, we observed a total atelectasis of the left (Figure 1).
A bronchoscopy was performed and revealed small grayish lesions in the right upper lobe, and decreased bronchial size due to persistent bronchospasm in the right middle lobe. In the upper left lung, light greenish mucus was found with plugs that occluded the main bronchus, which caused an extensive bronchial collapse (Figure 2). During the procedure, cytologic samples were taken and BAL of the left lung was performed, toward the identification of Mycobacterium tuberculosis, gram-negative bacteria, and fungi. During bronchoscopy, the patient presented desaturation. A control CXR showed complete recovery of the left lung atelectasis. Following the procedure, the patient's condition improved; she was hemodynamically stable while weaning vasopressors and sustained an optimal renal function.
On the sixth day of admission, a second bronchoscopy was performed and BAL with 50 cc of saline in the right upper lobe, where thickened fibrous tissue was found, and in the left upper lobe, which evidenced edematous areas with reddish-white plaques adherent to the bronchial walls. Serum galactomannan antigen test was positive.
One week after admission, the patient was recovering, hemodynamically stable without vasopressors, successfully extubated, and discharged from the intensive care unit 2 days later.
The BAL's cultures evidenced filamentous fungi, identified as Aspergillus fumigatus (Figure 3), so 200 mg/day of voriconazole was introduced. The patient showed clinical improvement and was discharged from our hospital.
The pathological study of the uterus showed that the membranous-spongeous material of the endometrial cavity appeared to be adhered to the myometrial thickness of the uterus and cervix, and additionally dilated and congestive vascular structures were evidenced. Furthermore, macroscopic samples confirmed some fungal structures, tabicated hyphae and micelles.