PMC4904540_01
Radiological and bronchoscopic findings. (a) Radiological findings. (A) Chest radiography (CRx) at hospital admission (day 1). (B) Computed tomography revealing small lingula consolidation (day 2). (C) CRx at ICU admission with new bilateral infiltrates (day 3). (D) CRx after 24 h of ICU admittance showing bilateral atelectasis (day 4). (b) Bronchoscopic findings. (A) Necrotic detritus and pseudomembrane in the right upper lobe. (B) Right upper lobe and right carina with an extensive deposit of necrotic material. Bronchoscopic biopsy was performed and revealed the presence of fungus with hyphae suggestive of Aspergillus. (C) Involvement of intermediate bronchus. (D) The orifice of bronchus in the culmen was not visible because of a large quantity of necrotic material. Bronchial wash fluid revealed the presence of Aspergillus. (E) Necrotic detritus and pseudomembrane in the left upper lobe. (F) Involvement of culmen, left carina, and lingula.
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Chest radiography was normal (Figure 1(a)(A)). Thoracic CT scan ruled out pulmonary thromboembolism but a small lingula consolidation was observed (see Figure 1(a)(B)). However, 24 hours later she developed severe mixed acute respiratory failure with severe hypoxemia (pO2 : FIO2 of 100 mmHg) and respiratory acidosis with pCO2 of 73 mmHg associated with new radiographic infiltrates (Figure  1(a)(C)), requiring admission to the Intensive Care Unit (ICU), emergent orotracheal intubation, and initiation of invasive mechanical ventilation. A severe obstructive pattern was observed with impossibility of ventilation and chest radiography revealed complete bilateral infiltrates (Figure 1(a)(D)). Fiber-optic bronchoscopy showed a large quantity of necrotic material at the distal bronchial tree, with impossibility of progress with the bronchoscope to subsegmental bronchi (Figure 1(b)).
Pathological findings. (a) Lung. The image shows left and right lungs with bilateral necrotizing pneumonia with vascular invasion. Left lung weight: 875 gr. Right lung weight: 1040 gr. (b) Trachea. The trachea and main bronchi affected by invasive aspergillosis. (c) Heart. The white nodule in the left ventricle was reported as aspergilloma. (d) Brain. Several hemorrhagic and necrotic areas caused by septic microemboli of Aspergillus.
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A forensic autopsy was performed showing invasive pulmonary aspergillosis (IPA) with disseminated infection involving lungs (bilateral necrotizing pneumonia), brain (necrotic and hemorrhagic spots suggesting septic emboli), heart, and kidneys (see Figure 2).