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Tracheal Perforation and Subcutaneous Emphysema Secondary to Pseudomembranous Invasive Aspergillus Tracheobronchitis
Kazushige Shiraishi1, Takkin Lo2,3
1Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA.
Introduction:
Aspergillus is a ubiquitous fungus causing various pulmonary diseases depending on the host's immune status. Aspergillus tracheobronchitis, a rare form of invasive aspergillosis, primarily affects severely immunocompromised or critically ill patients. We present the first known case of Aspergillus tracheobronchitis complicated by tracheal perforation and subcutaneous emphysema successfully treated with conservative endotracheal tube manipulation.
Case Description:
A 64-year-old male with type 2 diabetes mellitus presented with generalized weakness and abdominal discomfort, later diagnosed with a perforated cecum requiring right colectomy. His postoperative course in the intensive care unit was complicated by septic shock, acute kidney injury, and failed extubation due to airway compromise. Seven days after the failed extubation, he developed subcutaneous emphysema in the neck. Chest computed tomography scan showed neck, left chest wall, and mediastinal emphysema. Bronchoscopy identified a focal black necrotic lesion on the left proximal tracheal wall and multiple small mucosal ulcerations throughout the proximal to distal trachea. The endotracheal tube was advanced beyond proximal tracheal necrotic lesion. Subcutaneous emphysema reduced overnight, suggesting that the lesion was the source of the air leak. Bronchial washings confirmed Aspergillus fumigatus, establishing a diagnosis of invasive Aspergillus tracheobronchitis. Treatment with voriconazole prevented further expansion of emphysema, which gradually resolved.
Conclusion:
Subcutaneous emphysema in ventilated patients with tracheobronchitis is a rare and challenging complication. This case demonstrates successful management through endotracheal tube manipulation to tamponade the lesion, highlighting subcutaneous emphysema as a potential manifestation of Aspergillus tracheobronchitis and offering a minimally invasive treatment approach.
Learning Points:
Subcutaneous emphysema may present as a manifestation of Aspergillus/fungal tracheobronchitis.Aspergillus tracheobronchitis should be considered in patients with predisposing factors such as lung transplantation, acquired immunodeficiency syndrome (AIDS), diabetes mellitus, chronic obstructive pulmonary disease, and malignancies.Tracheal perforation caused by Aspergillus tracheobronchitis can be managed through endotracheal tube manipulation.
Insights
This case study presents a rare instance of Aspergillus tracheobronchitis complicated by tracheal perforation and subcutaneous emphysema. Successful conservative management involved endotracheal tube manipulation, highlighting a minimally invasive approach for this fungal infection.
Area of Science:
- Pulmonology
- Infectious Diseases
- Critical Care Medicine
Background:
- Aspergillus is a ubiquitous fungus causing pulmonary diseases.
- Aspergillus tracheobronchitis is a rare invasive aspergillosis affecting immunocompromised patients.
- Subcutaneous emphysema is a rare complication in ventilated patients with tracheobronchitis.
Purpose of the Study:
- To report the first case of Aspergillus tracheobronchitis complicated by tracheal perforation and subcutaneous emphysema.
- To describe a successful conservative management strategy for this rare condition.
- To emphasize subcutaneous emphysema as a potential sign of Aspergillus tracheobronchitis.
Main Methods:
- A 64-year-old male with type 2 diabetes mellitus presented with complications including septic shock and airway compromise post-colectomy.
- Diagnosis of Aspergillus tracheobronchitis was confirmed via bronchoscopy and bronchial washings (Aspergillus fumigatus).
- Conservative management involved advancing the endotracheal tube to tamponade the tracheal lesion and initiating voriconazole treatment.
Main Results:
- The patient developed subcutaneous emphysema, mediastinal emphysema, and tracheal perforation.
- Advancing the endotracheal tube led to a reduction in subcutaneous emphysema, indicating successful management of the air leak.
- Voriconazole treatment prevented further emphysema progression, with gradual resolution of the condition.
Conclusions:
- Subcutaneous emphysema can manifest as a complication of Aspergillus tracheobronchitis.
- Aspergillus tracheobronchitis should be considered in at-risk patients (e.g., those with diabetes, malignancies, or immunosuppression).
- Endotracheal tube manipulation offers a minimally invasive approach for managing tracheal perforation in Aspergillus tracheobronchitis.
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