P172 First report of Aspergillus tamarii producing influenza associated invasive pulmonary Aspergillosis

POSTER SESSION 2, SEPTEMBER 22, 2022, 12:30 PM - 1:30 PM: OBJECTIVE: Multiple infections can occur after 2009, pandemic influenza, including fungal and bacterial infections, but data from India are limited. To our knowledge, this is the first reported case of influenza-associated invasive pulmonary aspergillosis (IAPA), caused by Aspergillus tamarii, after infection with pandemic (H1N1) 2009 which was preceded by COVID-19, 20 months before. METHODS AND RESULTS: A 33-year-old male, known asthmatic, had been hospitalized elsewhere in August 2020 with COVID-19 pneumonia for 50 days and had been on mechanical ventilation for 37 days. He had no residual respiratory symptoms 3 months after recovery from COVID-19. He was admitted to Jupiter Hospital in April 2022 with fever, cough, and dyspnea for 8 days, which developed after a cold bath in a temple. HRCT (chest) showed ground glass opacities (GGOs), crazy paving, nodules, and traction bronchiectasis. Review of previous HRCT showed that only GGOs were present (Fig. 1). At admission, the nasopharyngeal swab was positive for pandemic (H1N1) 2009 in the filmarray respiratory panel and no other pathogen was detected. He was treated with oseltamivir. Expectorated sputum examination showed a heavy load of thin septate hyphae, with acute angle branching, resembling Aspergilllus species (Fig. 2). Serum galactomannan was positive (1.8). Based on these features he was diagnosed as a case of probable IAPA and initiated posaconazole (PCZ) treatment. Sputum fungal culture was positive and was identified by MALDI TOF MS as A. tamarii. A. tamarii has been rarely encountered as a human pathogen. Case reports of its involvement in eyelid infection, keratitis, invasive sinonasal infection, and onychomycosis exist. Sensititre MICs were 0.0625 mcg/ml, 0.125 mcg/ml, 0.0625 mcg/ml, and 0.125 mcg/mL for itraconazole, voriconazole, PCZ, and for isavuconazole (ISVCZ) respectively. The usually obtained PCZ trough level with standard dose is 1.2 mg/l which generates AUC of 200R. The usually obtained ISVC) trough level with standard dose is 3 mg/l which generates AUC of 100R. The PKPD index, AUC/MIC of 100, is needed with both these azoles for a therapeutic effectR. Therefore, it would be possible to treat this infection with any of these azoles. PCZ was continued in view of the easy availability of therapeutic drug monitoring (TDM) to assure adequate drug exposure, lower cost, and clinical improvement which had already occurred. CONCLUSION: An infection due to a rare Aspergillus species needs correct identification, MIC determination, and PKPD consideration for appropriate drug selection and management.