Clinical Image
An accidental finding during bronchoscopy for tracheostomy


    E.R. Eijsink (1), L. Dawson (1), R.N. van Rossem (2), L.C. Urlings-Strop (1)
    Departments of 1. Intensive Care and 2. Pulmonology, Reinier de Graaf Gasthuis, Delft, the Netherlands 


    E.R. Eijsink -
    Clinical Image

    An accidental finding during bronchoscopy for tracheostomy

    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.

    Invasive tracheobronchial aspergillosis is an infection that mainly occurs in immunocompromised patients.[1] It is also common in influenza and COVID-19,[2,3] but other ventilated patients can also be at risk. Early detection of invasive aspergillosis is important since delayed diagnosis leads to high mortality rates. At first glance, this patient may not seem immune incompetent. However, even denoted as not significant, she did have a splenic marginal zone lymphoma and intensive care patients in general are at risk for invasive aspergillosis. This case illustrates the necessity to be alert for [secondary] mycological infections in the ICU, especially in patients with severe infections combined with multiple organ dysfunction and the use of corticosteroids during hospitalisation.

    Tracheitis caused by Aspergillus fumigatus in a patient with Legionnaires' disease.


    All authors declare no conflict of interest. No funding or financial support was received.

    Written informed consent was obtained from the patient for the publication of this case.



    1. Bassetti M, Azoulay E, Kullberg B, et al. EORTC/MSGERC Definitions of Invasive Fungal Diseases: Summary of Activities of the Intensive Care Unit Working Group. Clin Infect Dis. 2021;72(Suppl_2):S121-7.
    2. van de Veerdonk FL, Brüggemann RJ, Vos S, et al. Covid-19-associated aspergillus tracheobronchitis: The interplay between viral tropism, host defence, and fungal invasion. Lancet Respir Med. 2021;9:795-802.
    3. Nyga R, Maizel J, Nseir S, et al. Invasive tracheobronchial aspergillosis in critically ill patients with severe influenza. A clinical trial. Am J Respir Crit Care Mede. 2020;202:708-16.