Rapidly progressive pseudomembranous Aspergillus tracheobronchitis diagnosed by bronchoscopy in a mechanically...

Aspergillus tracheobronchitis (AT) is a rare and severe manifestation of invasive aspergillosis, primarily affecting immunocompromised patients. The pseudomembranous subtype is associated with high mortality, particularly among those requiring mechanical ventilation. We report the case of an 86-year-old woman with nephrotic syndrome receiving corticosteroid and cyclosporine therapy who developed respiratory failure following emergency surgery for sigmoid colon perforation. After being admitted to the intensive care unit and placed on mechanical ventilation, she developed worsening oxygenation on ICU day 7. Chest computed tomography revealed bilateral ground-glass opacities, and serum β-D-glucan levels were elevated, initially raising suspicion for Pneumocystis pneumonia. Bronchoscopy on ICU day 12 showed no airway abnormalities,　but repeat bronchoscopy on day 14 demonstrated extensive tracheal pseudomembranes and a yellowish endobronchial plaque. Cytological and microbiological examinations confirmed Aspergillus fumigatus. Intravenous voriconazole was promptly administered, but her respiratory failure progressed, and she died on ICU day 16. Clinicians should consider AT in patients with progressive pneumonia after major surgery regardless of immune status, particularly when bacterial infection is excluded or antibiotic response is poor. Early and repeated bronchoscopy is crucial for timely diagnosis, and empirical antifungal therapy should be promptly considered to improve outcomes in suspected cases.