Troubled waters and puzzled doctors

Author:

Vasireddy Teja, Bibhuti Saha Hod, Soumendranath Haldar (IN)

Abstract:

Introduction: Drowning and near drowning are catastrophic events that occur unexpectedly in the lives of individuals who are often young and otherwise healthy. The worldwide numbers of drowning victims per year vary between 1,40,000 and more than 500000 and according to drowning data, the frequency of near drowning has to be extrapolated and is estimated to be from two to twenty-fold more common than the reported drownings. The most common fungal species recorded are Pseudallescheria Boydii and aspergillus species. Rare cases of aspergillosis have been reported in immunocompromised individuals after non-fatal drowning. These fungi are ubiquitous and present in soil, manure, sewage, polluted water and decaying vegetation.
Case Report: A 24 years female immunocompetent patient with history of near drowning 8 years back came with chief complaint of hemoptysis for 2 months most drowning intermittently persisted since that episode for 8years, during that episode patient had history of hemothorax and chest drain was done after 2months hemoptysis developed which is non resolving, associated with intermittent cough and fever. Initially amount was streaky to one-fourth cup per episode but gradually increased to half to one cup per episode. Patient was investigated multiple times at many centers but definitive diagnosis and definitive treatment could not be done and in one center CT guided biopsy was done and they suggested could be mucoromycosis and patient came to us for second opinion. On examination no specific signs were present; hence patient was investigated and routine blood investigations were within normal limits but radiological examination revealed a small nodule in left lower zone of lung, hence we proceeded with fine needle aspiration from the lesion which revealed septate fungal hyphae with round conidia and neutrophilic infiltration in the surrounding zone and PAS stain was positive with features resembling Aspergillus species. Serum galactomannan was 5.36 and culture from the aspirate grew Aspergillus Fumigatus within 2 weeks of inoculation. Hence, patient was started on tab. voriconazole 200mg;on follow up after 6 weeks patient was still symptomatically not better and radiologically nodule size was increasing inspite of good compliance;hence TDM was planned and it showed value of 0.4;there were no drug drug interactions or history of drug food interactions and her genotype study was normal hence brand was changed and repeat TDM was 1.3 and after 3 months patient lesion decreased in size and symptomatically cured.
Discussion: Drowning and near drowning can lead to various outcomes in young and healthy individuals. Fungi known to cause invasive disease after non-fatal drowning include P.boydii and to lesser degree aspergillus species.Signs and symptoms of invasive pulmonary aspergillosis are missed due to low index of suspicion causing delayed diagnosis.

Abstract Number: 82

Conference Year: 2024

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