title: Fatal invasive aspergillosis: a rare co-infection with an unexpected image presentation in a patient with dengue shock syndrome.
abstract: BACKGROUND
  Pulmonary infiltration and pleural effusion caused by permeability syndrome are the hallmark of pulmonary manifestation of dengue cases.
  
  
  OBJECTIVE
  We report a 95-year-old chronic obstructive pulmonary disease case having dengue shock syndrome. Chest X-ray examination revealed diffuse lung infiltration. However, bilateral pneumotoceles were unexpectedly found in computed tomography (CT) images. Dengue virus type 2 infection was confirmed by virus culture, serology and reverse transcriptase-polymerase chain reaction. Profound shock with bilateral lung infiltration developed rapidly in 2 days with supportive care and empirical ampicillin/ sulbactam. Bronchoscopy revealed a whitish plaque over bilateral upper bronchi. Biopsy via bronchoscopy revealed moulds with vascular invasion. Culture of bronchial alveolar lavage yielded Aspergillus flavus. The patient died despite amphotericin B treatment, which was started since finding the whitish plaque with bronchoscopy examination.
  
  
  CONCLUSIONS
  Besides to considering capillary leakage syndrome, our case report and literature review alert clinicians that CT and bronchoscopy may help to identify the true pathogen though all cases with concurrent dengue and Aspergillus infections had fatal outcomes.
authors.affiliation: Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Hui-Ching
authors.initials: HC
authors.lastname: Wang
authors.affiliation: Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan.
authors.forename: Ko
authors.initials: K
authors.lastname: Chang
authors.affiliation: Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.|Department of Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.|Division of Clinical Microbiology, Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Po-Liang
authors.initials: PL
authors.lastname: Lu
authors.affiliation: Department of Pathology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan.
authors.forename: Kun-Bow
authors.initials: KB
authors.lastname: Tsai
authors.affiliation: Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan.
authors.forename: Huang-Chi
authors.initials: HC
authors.lastname: Chen
mesh_terms: D000369:Aged, 80 and over; D001999:Bronchoscopy / Q000379:methods; D060085:Coinfection / Q000000981:diagnostic imaging* / Q000382:microbiology; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D055732:Pulmonary Aspergillosis / Q000000981:diagnostic imaging* / Q000382:microbiology; D029424:Pulmonary Disease, Chronic Obstructive / Q000382:microbiology*; D019595:Severe Dengue / Q000175:diagnosis* / Q000188:drug therapy
keywords: aspergillosis-bronchoscopy-dengue shock syndrome