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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 26-29

Post-COVID primary laryngeal aspergillosis


1 Department of ENT and Head and Neck Surgery, Dr. Pinnamaneni SIMS and RF, Vijayawada, Andhra Pradesh, India
2 Department of ENT, Dr. Pinnamaneni SIMS and RF, Vijayawada, Andhra Pradesh, India

Date of Submission03-Jun-2022
Date of Acceptance08-Sep-2022
Date of Web Publication14-Oct-2022

Correspondence Address:
Dr. Pandiri Jagruthi
Department of ENT, Dr. Pinnamaneni SIMS and RF, Chinnoutpalli, Gannavaram, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_4_22

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  Abstract 


Ever since the first case reported in 2019, covid 19 has been affecting the health and well-being of people globally. Covid 19 infection, through its post recovery immunocompromised state, has opened a door for many opportunistic infections in the affected patients. Aspergillosis is one such opportunistic infection. Among the multiple species of aspergillus, the most common species causing aspergillosis are A.fumigatus and A.flavus. Like any other fungal infection, in aspergillosis, larynx is involved secondarily as a consequence of advanced stages of lower respiratory tract infection or by hematogenous spread from a primary site. Here we are reporting a case of primary aspergillosis of larynx in a 41-year-old immunocompetent male patient who has been affected with covid 19 infection twice in a span of 9 months and presented with history of hoarseness of voice.

Keywords: Laryngeal aspergillosis, post-COVID aspergillosis, primary laryngeal aspergillosis


How to cite this article:
Madala SR, Jagruthi P, Murthy P S, Anusha A. Post-COVID primary laryngeal aspergillosis. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2022;6:26-9

How to cite this URL:
Madala SR, Jagruthi P, Murthy P S, Anusha A. Post-COVID primary laryngeal aspergillosis. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Nov 30];6:26-9. Available from: https://www.aiaohns.in/text.asp?2022/6/1/26/358578




  Introduction Top


Aspergillus species are ubiquitous saprophytic fungi that grow in soil and decaying fruits and vegetables. The inhaled spores of fungus settle on the mucosa of airways and grow into characteristic hyphae. They invade the deeper tissues and cause clinical symptoms when the immune system of the patient becomes compromised. Aspergillosis is essentially an opportunistic infection, host immunity being an important factor in the production of clinical disease. However, it is rarely reported in immunocompetent patients with about 27 patients reported in the literature.[1] This report presents a case of post-COVID primary laryngeal aspergillosis in a middle-aged immunocompetent male patient.


  Case Report Top


A 41-year-old male patient who is a nonsmoker and businessman by occupation came to the ENT outpatient department with a chief complaint of change in voice in the last 3 days which was sudden in onset, progressive, hoarse in nature, and continuous throughout the day with no aggravating and relieving factors. He had a history of COVID-19 infections twice in 9 months, confirmed by reverse transcription–polymerase chain reaction 9 months ago, received treatment at an isolation center for 5 days later hospitalized for 5 days, and received intravenous (IV) remdesivir, anticoagulants, and IV steroids. The second infection 18 days before the onset of hoarseness, confirmed by rapid antigen test, received azithromycin, doxycycline for 5 days, and ivermectin for 3 days, and there was no history of steroid usage or oxygen supplementation during the second COVID infection. The patient had no history of comorbidities such as diabetes, hypertension, bronchial asthma, or pulmonary tuberculosis and was not on any regular medication. There was no history of a rise in blood glucose levels during the episode of COVID infection or during steroid therapy. There was no history of long-term usage of antibiotics in the past, hematological malignancies, organ transplantation, and postradiation status. The general and systemic examinations of the patient were normal.

Routine blood investigations were all within normal limits.

Video laryngoscopy revealed a whitish devitalized patch over the anterior one-third of bilateral vocal cords [Figure 1].
Figure 1: Preoperative laryngoscopy

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Computed tomography (CT) of the neck with chest showed no obvious abnormality in the chest and no obvious focal lesions in the neck and larynx [Figure 2].
Figure 2: CT neck and chest. CT: Computed tomography

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CT paranasal sinuses revealed minimal mucosal thickening in bilateral ethmoid air cells with DNS to left and septal spur impinging on the left inferior turbinate [Figure 3].
Figure 3: CT paranasal sinuses. CT: Computed tomography

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Microlaryngeal surgery and excision were done and excised tissue is sent for potassium hydroxide (KOH) mount, fungal culture, and biopsy. KOH mount turned out to be positive for fungal elements with septate pseudohyphae. Fungal culture revealed the growth of slender septate hyphae with branching at 45° suggesting Aspergillus. Histopathology showed fibrous stromal bits focally lined by stratified squamous epithelium showing ulceration covered with necroinflammatory slough. There were no features suggestive of atypia.

Postoperative treatment

The patient was discharged on the next day and received oral posaconazole in the form of a 300-mg tablet once daily for 1 month.

Video laryngoscopy showed healed vocal cords after 3 weeks of the postoperative period [Figure 4].
Figure 4: Video laryngoscopic image - three weeks postoperative

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  Discussion Top


Aspergillosis is an opportunistic fungal infection caused by the genus Aspergillus of the family Aspergillaceae. Fungal infections are most commonly seen in tropical countries due to the growth favorable conditions provided by the humidity. Other patient factors such as hematological malignancies, diabetes, posttransplant immunosuppressive therapies, and radiotherapies, which result in an immunocompromised state, may also play a role in opportunistic fungal infections such as mucormycosis and aspergillosis.

The major systemic defense against fungi is phagocytosis by macrophages and granulocytes. Any systemic disorder resulting in neutropenia and impaired functioning of macrophages can make the host susceptible to opportunistic infection. Local factors such as the mucosal barrier also prevent fungal colonization in normal individuals. An insult to this barrier in the form of vocal abuse, laser resections, and trauma along with antibiotic and steroid inhaler use can predispose to opportunistic infection even in immunocompetent individuals.[2] In recent times, immune dysregulation is also being caused by SARS-CoV-2 infection in patients who recovered from COVID-19 infection.[3] In immunocompetent patients with no events to explain the development of this rare infection, oral sex should be ruled out as a predisposing factor.[4]

Involvement of the larynx in such fungal infections is almost always secondary.[5] Based on the depth of involvement, aspergillosis can be superficial, involving only the mucosal lining and deep, which involves the deeper tissues and disseminates through the blood to distant organs such as lungs, heart, brain, gastrointestinal tract, and lymph nodes. It is necessary to have a definitive confirmation by culture or nonculture technique, including (i) direct microscopic examination with the optical brightener methods, Calcofluor or Blankophor, which may increase the sensitivity and specificity for detecting Aspergillus-like features, and (ii) culture on fungal-specific media at 37°C for 2–5 days, if positive, morphological features of Aspergillus can be identified under the microscope or the DNA sequencing may be used in reference laboratories to identify the species accurately, but usually culture yield is low and a negative result does not exclude the diagnosis of invasive aspergillosis.[6]

The case described here can be considered one of a kind as the larynx is primarily involved with no evidence of fungal invasion in the upper or lower airways. The patient has no prior comorbidities except a history of COVID-19 infection twice and a history of IV steroid therapy received during the first episode. The predisposing factors in this patient could be defective systemic and local defense mechanisms in the form of immune downregulation in post-COVID status and breach in the mucosal barrier as a result of vocal abuse.


  Conclusion Top


Larger studies need to be conducted on post-COVID-recovered patients with longer follow-up periods to identify the sequelae of immune downregulation. Regular follow-ups help in the early detection and treatment of local opportunistic infections and avoid their systemic spread.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dutta M, Jotdar A, Kundu S, Ghosh B, Mukhopadhyay S. Primary laryngeal aspergillosis in the immunocompetent state: A clinical update. Braz J Otorhinolaryngol 2017;83:228-34.  Back to cited text no. 1
    
2.
Sheth MC, Paul RR, Mathews SS, Albert RR. Isolated aspergillus laryngitis: Spectrum, management, and review of literature. J Voice 2020;28:S0892-3.  Back to cited text no. 2
    
3.
Ran Y, Lu Y, Cao L, Li C, Dai Y, Yang H, et al. Primary laryngeal aspergillosis related to oral sex? A case report and review of the literature. Med Mycol Case Rep 2012;2:1-3.  Back to cited text no. 3
    
4.
Jing Y, Luo L, Chen Y, Westerberg LS, Zhou P, Xu Z, et al. SARS-CoV-2 infection causes immunodeficiency in recovered patients by downregulating CD19 expression in B cells via enhancing B-cell metabolism. Signal Transduct Target Ther 2021;6:345.  Back to cited text no. 4
    
5.
Doloi PK, Baruah DK, Goswami SC, Pathak GK. Primary aspergillosis of the larynx: A case report. Indian J Otolaryngol Head Neck Surg 2014;66 Suppl 1:326-8.  Back to cited text no. 5
    
6.
Song G, Liang G, Liu W. Fungal co-infections associated with global COVID-19 pandemic: A clinical and diagnostic perspective from China. Mycopathologia 2020;185:599-606.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
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Case Report
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