Central nervous system Aspergillus quadrilineatus infection in a COVID‐19 patient, a case report and literature review

BACKGROUND: Viral pneumonia such as COVID‐19‐associated aspergillosis could increase susceptibility to fungal super‐infections in critically ill patients. METHODS: Here we report a pediatric case of Aspergillus quadrilineatus cerebral infection in a recently diagnosed COVID‐19‐positive patient underlying acute lymphocytic leukemia. Morphological, molecular methods, and sequencing were used to identify this emerging species. RESULTS: Histopathological examination showed a granulomatous necrotic area containing dichotomously branching septate hyphae indicating a presumptive Aspergillus structure. The species‐level identity of isolate growing on brain biopsy culture was confirmed by PCR sequencing of the β‐tubulin gene as A. quadrilineatus. Using the CLSI M38‐A3 broth microdilution methodology, the in vitro antifungal susceptibility testing demonstrated 0.032 μg/mL MIC for posaconazole, caspofungin, and anidulafungin and 8 μg/mL against amphotericin B. A combination of intravenous liposomal amphotericin B and caspofungin therapy for 8 days did not improve the patient's condition. The patient gradually continued to deteriorate and expired. CONCLUSIONS: This is the first COVID‐19‐associated cerebral aspergillosis due to A. quadrilineatus in a pediatric patient with acute lymphocytic leukemia. However, comprehensive screening studies are highly recommended to evaluate its frequency and antifungal susceptibility profiles. Before being recommended as first‐line therapy in high‐risk patients, more antifungal susceptibility data are needed.