de intensivist

Case
A 74-year-old woman with a medical history of splenic marginal zone lymphoma with splenomegaly and bone marrow localisation, for which no treatment was necessary, was admitted to the intensive care unit (ICU) due to respiratory failure because of Legionnaires’ disease. Sputum culture showed Legionella pneumophila serotype 1 which was treated with levofloxacin. Mechanical ventilation was necessary, including sedation and prone positioning in order to ventilate her adequately. Nevertheless, her respiratory condition was poor and permissive hypercapnia was required. Moreover, haemodynamic support was needed as was renal replacement therapy with continuous venovenous haemodialysis due to acute kidney injury. A CT scan ruled out pulmonary embolism, but did show extensive consolidations in both lungs. Suspected organised pneumonia motivated starting prednisone 2d25mg. After two weeks, the patient improved considerably and the ventilator settings could be reduced. Because of ICU-acquired weakness, we decided to perform a tracheostomy to facilitate weaning. As an incidental finding, bronchoscopy performed during the procedure showed severe tracheitis (figure 1). Due to the white plaques and presence of cobble stones, the suspicion of aspergillosis immediately arose. Strikingly, the infection extended from the tip of the tube to the carina and ended at the beginning of both main bronchi. Normal tissue was present above the tube and below the carina. Bronchial lavage fluid indeed showed Aspergillus fumigatus which was initially treated with intravenous voriconazole and anidulafungin. The strain turned out to be voriconazole B sensitive and so treatment was switched to monotherapy. In addition, local treatment was given with nebulised amphotericin B until the tracheal cannula was removed. She recovered and was discharged to the ward 41 days after her admission to the ICU.