A Rare Case of Aspergillus Empyema Thoracis as a Complication of COVID-19 Pneumonia

Introduction: Aspergillus is a ubiquitous mold that manifests as a wide range of clinical disease. Although there have been recorded cases of coronavirus disease-associated invasive pulmonary aspergillosis, aspergillus empyema thoracis remains an exceedingly rare entity altogether, with no documented reports specifically in association with antecedent COVID-19 pneumonia. We report this case in view of the exceptional rarity of pleural Aspergillosis occurring in an otherwise healthy individual with no lung pathology prior to COVID-19 infection. Presentation of Case: A 68 year old female with history of hypertension, hyperlipidemia and recently diagnosed COVID-19 infection from an ER visit one week prior presented to a community hospital with progressive shortness of breath and hypoxemic respiratory failure, for which she was treated with tocilizumab, steroids, ceftriaxone and azithromycin due to concerns for bacterial superinfection. She did not receive remdesivir due to time course of initial symptom onset. Her course was complicated by hydropneumothorax requiring multiple tube thoracostomies for persistent right pneumothorax. Pleural fluid analysis was exudative and grew aspergillus fumigatus, and she was subsequently started on voriconazole with broad spectrum antibiotics. Initial sputum cultures were negative however repeat tracheal aspirates grew mycobacterium avium complex, which resulted post-mortem. There was no history of diabetes or immunosuppressed state prior to admission. No bronchopleural fistula was identified on imaging or bronchoscopy. She experienced a protracted hospitalization with severe ARDS and was transferred to a tertiary care facility for refractory hypoxemia with administration of pulmonary vasodilator for salvage therapy with no improvement. She was not deemed a candidate for transplant or extracorporeal membrane oxygenation due to factors including active infection and age. She ultimately experienced cardiopulmonary arrest and expired on hospital day 46