Dual Cytomegalovirus and Aspergillus Pneumonia Following Influenza B Infection in a Patient with Polyarteritis Nodosa

Abstract

A 72-years-old woman of polyarteritis nodosa had fever, running nose, and nasal obstruction for 3 days. In emergency room, rapid influenza diagnostic test in nasopharyngeal swab was positive for influenza B on October 31, 2015. Chest X-ray (CXR) showed slight infiltration on bilateral lungs. A white blood cell count was 16,100/μL and an elevated C-Reactive Protein (CRP) level was 238.0 mg/L. Initial renal function was normal. Other data of laboratory testing were tabulated in Table 1.Initially, zanamivir inhalation therapy and intravenous moxifloxacin were given. However, high spiking fever was still off and on. As increased CRP (315.7 mg/L), leukocytosis (24,500/μL) and worsening dyspnea, the patient was transferred to the intensive care unit on November 09. Bilevel positive airway pressure was used for non-invasive mechanical ventilation support. Antimicrobial therapy with piperacillin-tazobactam was initiated to replace moxifloxacin. Thereafter, fever was subsided. As acute renal failure occurred, continuous venovenous hemofiltration was performed.Followed-up CXR showed newly developed consolidation over right lung fields ( Figure 1A) and the sputum cultures yielded yeast-like organisms. Antimicrobial therapy was maintained with piperacillin-tazobactam. For the therapy of PAN, intravenous methylprednisolone 40 mg every 6 hours was given since November 20, AbstractPolyarteritis Nodosa (PAN) is a systemic necrotizing vasculitis that might require immunosuppressive therapy. We report on a 72-year-old woman of PAN with influenza B infection, who developed dual cytomegalovirus and Aspergillus pneumonia in the later course. Together with steroid therapy, delayed initiation of anti-CMV and anti-fungal therapy complicated the disease course. Early diagnosis and therapy for CMV and aspergillosis in the patients post-influenza attack are important, especially in those with steroid therapy.