Journal of Clinical and Diagnostic Research. 2022 Aug, Vol-16(8): DD03-DD05 3 3 DOI: 10.7860/JCDR/2022/57351.16790 Case Report Microbiology Section An Emerging Neglected Co-infection: Aspergillus fumigatus and Mycobacterium gordonae Co-infection in an Immunocompromised Patient CASE REPORT A 63-year-old male was admitted to the pulmonology department with complaints of cough with expectoration, breathlessness on exertion, loss of weight and appetite and malaise for the past three months. He gave no history of haemoptysis and fever. Patient was a chronic smoker with a known history of ischaemic heart disease with old myocardial infarction and post status percutaneous transluminal coronary angioplasty done in the year 2007. Right pleurectomy was done in the year 1990 due to alleged pneumothorax and was treated for three years. He developed COPD in the year 2015 for which he was hospitalised several times and underwent treatment at his native place. He had no history of systemic hypertension/Type 2 diabetes mellitus. At the time of admission, the patient was conscious, oriented and cachectic with complaints of breathing difficulty (SpO 2 -92% in room air). On auscultation severe crepitations were noted bilaterally over the lung bases. Patient was admitted and was advised for echocardiogram, X-ray chest, High Resolution Computed Tomography (HRCT) (chest), routine blood investigations, sputum for AFB, Gram staining, AFB culture and fungal culture. Patient was started on broad spectrum antibiotic (Injection Ceftriaxone 1g IV BD), oxygen support and other supportive medications. Chest X-ray [Table/Fig-1] and HRCT revealed extensive fibrosis with traction bronchiectasis, cavity formation in both upper lobes, centrilobular nodules with tree in bud configuration in both lungs and extensive bullous emphysematous changes with associated destruction of lung parenchyma. Echocardiogram showed regional wall abnormalities, sclerosed aortic wall, Left Ventricle Ejection Fraction (LVEF) - 45%, Pulmonary Arterial Systolic Pressure (PASP) was 55 mmHg and no evidence of pulmonary embolism. Three consequent sputum samples of the patient, collected on three days were positive for AFB by Ziehl Neelsen (ZN) method with a grade of 3+ [Table/Fig-2]. Sputum Gram stain revealed pus cells more than 25 per low power field, plenty of gram positive cocci in pairs, short chains and occasional cluster while routine bacterial culture of the sputum yielded normal flora of respiratory tract. Fungal culture on Sabouraud Dextrose Agar (SDA) yielded Aspergillus fumigatus after four days of incubation with colonies showing blue- green pigmentation [Table/Fig-3]. Lactophenol cotton blue mount demonstrated conidiophores with the characteristic features suggestive of Aspergillus fumigatus [Table/Fig-4]. Considering the HRCT report and the patient’s symptoms, sputum sample was sent for GeneXpert, Interferon Gamma Release Assay (IGRA) and ZN stain for AFB. Mycobacterium tuberculosis was not detected by GeneXpert (Cepheid) and IGRA was negative which ruled out Mycobacterium tuberculosis. Lowenstein Jensen medium yielded no growth during the first week of culture. Considering the positive report of Sputum for AFB and negative GeneXpert report, the patient sample was tested by PCR for NTM which was positive. After two weeks of incubation, LJ medium yielded bright yellow colonies [Table/Fig-5] which were confirmed to be acid fast bacilli by Ziehl Neelsen (ZN) stain and then subjected to species identification by Matrix Assisted Laser Desorption/Ionization Time- of-Flight Mass Spectrometry (MALDI-TOF-MS), which identified the colonies as M. gordonae. RANI KUMARAVEL 1 , PRIYADARSHINI SHANMUGAM 2 , R ALICE PEACE SELVABAI 3 Keywords: Chronic obstructive pulmonary disease, Gene Xpert, Non tuberculous mycobacteria, Pulmonary aspergillosis ABSTRACT Non Tuberculous Mycobacteria (NTM) commonly affect the immunocompromised patients afflicted with chronic pulmonary disease and other opportunistic infections such as Aspergillus species. Although the symptoms and signs are similar for both, early laboratory diagnosis and treatment would reduce the duration of hospitalisation and unnecessary exposure to antimicrobials. Since NTM and Aspergillus species co-infection is an emerging trend, and delay in diagnosis and treatment can cause major complications, it is essential to clinically suspect the same, and this will help in early diagnosis of the infection, keeping in mind the delayed growth of NTM and Aspergillus species in culture and the time taken to identify the infecting organism. Here, an interesting case of an immunocompromised 63-year-old male patient with Chronic Obstructive Pulmonary Disease (COPD) on frequent treatment who had symptoms of cough with expectoration, breathlessness on exertion, malaise, loss of weight and appetite for three months is reported. The patient was conscious, oriented and cachectic with complaints of breathing difficulty at the time of admission. Considering the positive report of Sputum for Acid Fast Bacilli (AFB) and negative GeneXpert report, the patient sample was tested by Polymerase Chain Reaction (PCR) for NTM which was positive. The patient was diagnosed with Mycobacterium gordonae (M. gordonae) and Aspergillus fumigatus co-infection. [Table/Fig-1]: Chest X-Ray: B/L upper lobes showing fibrotic areas. [Table/Fig-2]: ZN stain for acid fast bacilli from the patient’s sputum sample. (Images from left to right).