Antibacterials/corticosteroids
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Invasive pulmonary aspergillosis due to Aspergillus fumigatus: case report. A 61-year-old man developed invasive pulmonary aspergillosis (IPA) due to Aspergillus fumigatus during treatment with ceftobiprole, ceftriaxone, clarithromycin, levofloxacin, piperacillin/tazobactam and unspecified corticosteroid [not all routes and dosages stated]. The man had a history of cigarette smoking and asbestos exposure. In February 2018, he was admitted due to pneumonia, hypoxia and respiratory failure. Before the admission, he had a low grade fever since 1 month and dyspnoea with non-productive cough, which was non responsive to piperacillin/tazobactam, levofloxacin and ceftriaxone. In his previous admission, he was diagnosed with pneumonia. At the presentation, he was apyretic, had elevation in the vocal fremitus, localised crepitations in the left medium lobe and hypophonesis. The chest X-ray revealed left medium-lower lobe infiltrations. His partial pressure of oxygen was reduced to 78mm Hg, had thrombocytopenia with platelet count 130 × 103/mm3, elevated ALT 58 U/L and ALP 141 U/L. He was subsequently diagnosed with uncontrolled diabetes. Due to suspected influenza infection, he was started on oral oseltamivir 75mg, unspecified IV corticosteroids 60mg, 2 doses of oral clarithromycin 500mg and 3 doses of IV ceftobiprole 500mg. On day 3 of admission, his symptoms did not improve. He required 4 L/min of oxygen due to worsened hypoxia. The pulmonary CT scan and chest X-ray demonstrated diffuse alveolar destruction with a progression of bilateral multiple pulmonary nodules and a ground-glass appearance. On day 4 of admission, broncho-alveolar lavage (BAL) fluid PCR confirmed influenza-A H1N1. On day 9 of admission, his respiratory symptoms deteriorated requiring 7 L/min of oxygen. The BAL was positive for Aspergillus fumigatus fungus and galactomannan. Therefore, an A. fumigatus, co-infection was suspected and the man was treated with antifungal therapy including micafungin and isavuconazole. At the intiation of the antifungal therapy, he developed haemoptysis, progressive productive cough and need of 10 L/min oxygen therapy. He had tachycardia (110 bpm), tachypnoea (33 breaths/minute) and ventricular repolarisation seen in ECG. Due to aphonia and cough, he developed subscapular pain. Subsequently, a CT scan revealed progression of pulmonary lesions and the ground-glass appearance transformed to a tree-in-bud appearance with small diffused cavities. After a month from the admission, he had no oxygen requirement and was discharged with isavuconazole for 3 months with a diagnosis of IPA complicated with influenza. At 1 month and 4 month follow-up, CT scan revealed a significant improvement of consolidations, interstitial involvement and widespread micronodular findings. Saccaro LF, et al. Severe respiratory failure in an immunocompetent host with invasive pulmonary aspergillosis and h1n1 influenza. Infezioni in Medicina 28: 263-267, No. 2, 803499896 Jan 2020. Available from: URL: https://www.infezmed.it/media/journal/Vol_28_2_
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