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Acute Respiratory Distress Syndrome Due to COVID-19-Associated Pulmonary Aspergillosis with Rare Extensive Tracheobronchial Pseudomembranous Involvement: A Case Report

Summary

An elderly COVID-19 patient developed a rare and severe fungal infection caused by Aspergillus fungus in the airways, creating yellowish-white membrane-like deposits that blocked breathing. Despite identification of the fungus through examination and modern genetic testing, and treatment with antifungal medications, the patient’s condition worsened rapidly leading to organ failure and death. This case highlights how fungal infections can complicate COVID-19, especially in elderly patients on multiple medications, and stresses the importance of early recognition and immediate antifungal treatment.

Background

COVID-19-associated pulmonary aspergillosis (CAPA) significantly exacerbates clinical outcomes and mortality in COVID-19 patients. SARS-CoV-2 induces epithelial damage and immunosuppression, increasing susceptibility to opportunistic fungal pathogens including Aspergillus species. Pseudomembranous Aspergillus tracheobronchitis (PMATB) is a rare and severe manifestation of invasive pulmonary aspergillosis.

Objective

This case report describes an elderly male COVID-19 patient with extensive pseudomembranous involvement of the entire tracheobronchial tree caused by Aspergillus infection. The case highlights the diagnostic challenges and clinical management of CAPA, demonstrating the first reported instance of pseudomembranous adherence spanning from the glottis to the bronchi.

Results

Bronchoscopy revealed yellow-white, translucent pseudomembranes enveloping the entire subglottis, trachea, and bronchi with underlying hyperemic and edematous mucosa. Pathological examination and NGS confirmed Aspergillus fumigatus infection (92.4% of identified pathogens). Despite initiation of antifungal therapy with voriconazole and supportive measures, the patient developed multiorgan failure and died on January 18, 2023.

Conclusion

Early diagnosis and prompt antifungal intervention are paramount in managing CAPA. Bronchoscopy should be performed urgently when clinical suspicion warrants, particularly in high-risk COVID-19 patients with elevated inflammatory markers and fungal indicators. Prophylactic or empirical antifungal therapy should be considered before definitive diagnosis to optimize treatment outcomes in critically ill patients.
  • Published in:Mycopathologia,
  • Study Type:Case Report,
  • Source: PMID: 40742610, DOI: 10.1007/s11046-025-00971-5
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