Title : From myositis to mycosis: Invasive aspergillosis in a patient treated for presumed autoimmune disease
Abstract:
We present a diagnostically challenging case of disseminated invasive aspergillosis (DIA) in a 71-year-old male with recent E. coli bacteremia, acute kidney injury requiring hemodialysis (AKI-D), and autoimmune myositis treated with high-dose corticosteroids. The patient was initially hospitalized for progressive bilateral lower extremity weakness and was treated empirically for Guillain-Barré syndrome (GBS) and inflammatory myopathy, receiving IVIG, methylprednisolone (1g daily x5), and a prednisone taper. Extensive imaging and serologic workup, including negative myositis panel and muscle biopsy, failed to confirm a unifying diagnosis. The patient’s course was complicated by persistent thrombocytopenia, recurrent hypotension, and transfusion-dependent anemia. Despite serial transthoracic echocardiograms (TTEs) showing no evidence of endocarditis, a transesophageal echocardiogram (TEE) was deferred due to profound thrombocytopenia, delaying the evaluation for fungal endocarditis or embolic disease. After multiple admissions, he developed distributive shock and was found to have evidence of disseminated aspergillosis involving the lungs, spleen, liver, and myocardium, confirmed postmortem. This case highlights how prolonged immunosuppression and diagnostic inertia in a complex host may contribute to missed opportunities for early detection of opportunistic infections. Earlier TEE, empiric antifungal consideration, or tapering of immunosuppression in the absence of definitive autoimmune disease may have altered the clinical trajectory.
