A Case of COVID-19-associated Pulmonary Aspergillosis Diagnosed after Hemoptysis

An 86-year-old man suffered from COVID-19 and was treated at another hospital. He was transferred to our hospital due to hemoptysis and deterioration of respiratory condition. At our hospital, we treated with steroids and antibiotics and stopped the administration of cilostazol. His condition gradually improved. However, 24 days after onset of COVID-19 symptoms, he suffered a sudden pulmonary hemorrhage. Chest computed tomography showed a nodular shadow and ground glass opacities in the right lower and upper lobes, respectively. He was diagnosed with COVID-19-associated pulmonary aspergillosis (CAPA), following high serum antigen titer of Aspergillus and a positive sputum culture of Aspergillus fumigatus. Despite administration of antifungal drugs, he died 35 days after onset of COVID-19 symptoms.Globally, CAPA has become a serious concern in the management of severe cases of COVID-19 due to its associated high mortality rate. However, the diagnosis of CAPA is challenging, because CAPA can occur in immunocompetent patients and radiological findings, such as cavitations suggesting fungal infection, are not often seen. In addition, mycological evidence is complicated by decreased use of diagnostic bronchoscopy, which is necessary to protect health-care workers from aerosol exposure. Hemoptysis may be helpful for the diagnosis of CAPA. In patients with COVID-19, hemoptysis should prompt consideration of the possibility of CAPA.