Invasive Aspergillosis of the Abdominal Aorta with Multiple Peripheral Embolic Lesions

Invasive aspergillosis is an infection usually found in immunecompromised patients. Aortic invasion by Aspergillus spp. has rarely been reported even among immunocompromised patients. In this case, we saw invasive aspergillosis of the abdominal aorta with multiple peripheral aspergillus lesions. A 28-year-old woman was admitted for bone marrow stem cell transplantation due to severe aplastic anemia. After conditional chemotherapy, she received bone marrow stem cells. The patient was given a prophylactic antibacterial agent (trimethoprim with sulfamethoxazole), an antiviral agent (acyclovir) and an anti-fungal agent (micafungin). However, she had a neutropenic fever, which lasted for about 4 weeks. She was diagnosed with cytomegalovirus (CMV) pneumonia and treated with intravenous ganciclovir. The patient displayed a recurrent fever 4 weeks after the CMV pneumonia, as well as multiple tender, reddish nodular skin lesions on her trunk, legs and soles (Fig. 1). However, the upper part of her body showed no skin lesions. A biopsy of the skin lesions demonstrated an aggregation of fungal hyphae consistent with septic aspergillosis emboli. A serum aspergillus antigen test was positive, and the findings suggested invasive aspergillosis. The patient was treated with intravenous amphotericin B. Aspergillus flavus was confirmed with skin lesion culture. To find the septic embolism source, transthoracic echocardiography and computerized tomographic (CT) studies were performed. Transthoracic echocardiography showed no abnormalities suggesting endocarditis. The CT showed a narrowed abdominal aorta with peripheral edema, and splenic infarction (Fig. 2A, B). The narrowing was diffuse and about 6 cm long, with flow acceleration upon ultrasound examination. Velocity was about 3.9 m/sec suggesting a pressure gradient of 61 mmHg (Fig. 2C, D, Supplementary Video 1 in the online-only Data Supplement). Although she was treated with intravenous antifungal agents (amphotericin B and caspofungin) for 7 weeks, the aortic lesion progressed. We wanted to do bypass surgery from her axillary to femoral arteries and remove the diseased Invasive Aspergillosis of the Abdominal Aorta with Multiple Peripheral Embolic Lesions