A 64-year-old patient with a history of COPD on long-term treatment with bronchodilators and oral corticosteroids.
She was admitted for cough, hemoptoic expectoration and pain in left hemithorax.
Physical examination revealed fever and abolition of vesicular murmur on that side.
Blood analysis showed Hb 10.5 g/dL MCV 87HC 27 Leu 15.000 (N = 20%), normal rest.
A chest X-ray showed an alveolar infiltrate in the left upper lobe.
Empirical antibiotic treatment with ceftriaxone 1g/day was initiated.
In the following days, fever, asthenia, anorexia, expectoration persisted. A bronchoscopy showed no alterations in the bronchial tree.
Bronchoalveolar lavage cytology was negative for malignancy and culture for aerobic, anaerobic, and mycobacteria was negative.
A few days later a slight improvement was observed and in the absence of fever was discharged with the same antibiotic treatment.
Ten days later, he started again with a fever of 38 oC and had several episodes of instability when adopting the standing position, requiring him to remain in decubitus.
In the chest X-ray, an alveolar infiltrate persisted in the left upper lobe.
Blood cultures were negative, and sputum cultures where Aspergillus fumigatus was isolated on two occasions. Treatment with amphotericin B at a dose of 1 mg/kg/day was initiated.
In the following days, the patient had several presyncopes when adopting a standing position, without alterations in the neurological examination or electrophysiological changes.
Two days after starting antifungal treatment, a thoracic CT scan showed a cavitated infiltrate in the left upper lobe with a wide base of pleural implantation and in contact with the aortic arch.
After contrast administration, a hyperdense saccular area of 5 cm maximum diameter was observed in contact with aortic arch.
The diagnosis of a fungal aneurysm was suspected and an arteriography confirmed the presence of an aortic arch aneurysm with rupture of its wall, which required implantation of a Talent stent.
In the following days, the patient developed cough and sputum with low cough.
Fifteen days after admission the patient had a massive hemoptysis and died immediately.
