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Intensive care patient – continued

This article provides the second half of the ICU patient case study.
Intensive Care Patient Continued
© BSAC

In the last step you were introduced to a case study and had an opportunity to discuss your thoughts on the diagnosis and treatment options for this patient. We will now discuss what happened next.

A diagnosis of probable COVID-19 associated pulmonary aspergillosis (CAPA) was made and the patient commenced IV Voriconazole (300mg BD (11/04/2020)), but no therapeutic drug monitoring (TDM) was performed.

Question: Why is the case diagnosed as probable CAPA?
Question: Is TDM required in this case?
Despite antifungal therapy, the presence of Aspergillus in the respiratory tract persisted, with a NBL fluid being Aspergillus PCR and Galactomannan-EIA positive (I=7.6) on 15/04/2020, and azole sensitive Aspergillus fumigatus was also recovered from this specimen.
Question: What is the significance of the persisting positive results?

CT head showed evidence of sinusitis, but no acute intracranial pathology and the following day CT-pulmonary angiogram highlighted a new small cavitary lesion at the apex of the left lung. Despite on-going clinical intervention, the patient passed away on 21/04/2020.

Image of an x-ray - CTPA showing ground glass opacification and a tiny new cavitary lesion in the left apex, indicated by the arrow

CTPA showing ground glass opacification and a tiny new cavitary lesion in the left apex, indicated by the arrow

Image of a second x-ray - Extensive bilateral ground glass opacification and confluent consolidation

Extensive bilateral ground glass opacification and confluent consolidation

<img src="https://ugc.futurelearn.com/uploads/assets/01/cf/01cfd3a3-12ee-4ece-afe2-9c2e4acf026a.png" alt="Clinical time course of the COVID-19 associated aspergillosis in the case report patient. hospital admission 02/04/2020 SARS-COV-PCR positive BDG 500pg/ml. 09/04/2020 BDG >500pg/ml NBL – Aspergillus PCR positive and GM-EIA 8.3. 10/04/2020 BDG >500pg/ml Plasma- Aspergillus PCR positive and GM-EIA 4.9 CT chest – secondary infection. 11/04/2020 IV Voriconazole (300mg BD) commenced. 15/04/2020 NBL – azole sensitive A. fumigatus cultured, Aspergillus PCR positive and GM-EIA 7.6 CT head – sinusitis. 16/04/2020 CTPA – Cavitating lesion. 21/04/2020 Patient died.”>

If you require a screen-reader compatible version of the above image, this is available as a PDF.

In the comments, let us know:

  1. Were your answers in the last step similar to what actually happened?
  2. Is this a similar case to one you would experience in your own setting?
© BSAC
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Fungal Diagnostics in Critically Ill Patients

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