Invasive Aspergillosis With Heart Involvement in a Systemic Lupus Erythematosus Patient, an Extremely Rare Finding in Autopsy Examination. (21st September 2018)

• Record Type: Journal Article
• Authors: Huang, Xiaoyan; Heidarian, Amin; Shao, Charles
• Is Part Of: American journal of clinical pathology. Volume 150(2018)Supplement 1
• Page Start: S59
• Page End: S59
• Publication Date: 2018-09-21
• Subjects: Diagnosis, Laboratory -- Periodicals; Pathology -- Periodicals; 616.07
• DOI: 10.1093/ajcp/aqy091.146
• Languages: English
• ISSNs: 0002-9173

Abstract

Abstract: In the literature, there are rare cases of invasive aspergillosis with heart involvement. Here we report an extremely rare presentation of invasive aspergillosis as a necrotic cyst of heart in a patient with a history of systemic lupus erythematosus (SLE) who had overlapped symptoms from severe SLE flares. A 41-year-old woman from Guyana with a history of SLE, lupus nephritis stage IV, pleuritis, recurrent pulmonary hemorrhage, hypertension, chronic heart failure, diabetes mellitus, and pulmonary hypertension was admitted and treated with mycophenolate mofetil, prednisone, empirically antibiotic therapy (Vancomycin and Zosyn), and nephrology/respiratory support. The hospital course after 4 months became complicated with worsening of neurological, cardiology, and respiratory status. CT scan showed multifocal infarction of the brain, hypodense areas in the mitral valve, pericardial effusion, multifocal airspace consolidation in the lung, and heterogeneous areas in the thyroid. Multiple blood cultures failed to grow any organism. Postmortem autopsy revealed a 0.6-cm cystic lesion in the left ventricle of the heart and multifocal necrosis in the brain and thyroid. Microscopically, examination showed numerous dichotomous (45 degrees) branching hyphae with frequent septation consistent with invasive aspergillosis (confirmed with PAS stain) in the left ventricle myocardium, thyroid, lung, and brain. Although Aspergillus invasion of left atrium and interventricular septum is reported in immunocompromised patients, it is extremely rare to present as a myocardial cyst. This case emphasizes that invasive aspergillosis must be part of the differential diagnosis in patients with autoimmune diseases, particularly SLE patients, and raises the concern that these patients can be easily be misdiagnosed and mistreated as SLE flares, which can be fatal. Since image studies and clinical features, as well as blood culture, might not be diagnostic, possible biopsy of accessible places, such as thyroid in this case, and histopathology examination might be critical in this situation.