Umeda Shota, Nakajima Takahiro, Araki Osamu, Inoue Takashi, Maeda Sumiko, Chida Masayuki
Department of General Thoracic Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.24-0171. Epub 2025 Jul 10.
Approximately 20% of patients who contract coronavirus disease (COVID-19) pneumonia require oxygen therapy; of these patients, approximately 5% progress to acute respiratory distress syndrome, necessitating mechanical ventilation. The incidence of secondary infections among patients with COVID-19 is relatively low (16% for bacterial infections and 6.3% for fungal infections), but is predominantly observed in those with severe respiratory failure. Microvascular damage in COVID-19 can also lead to thrombus formation, causing infarctions, and in some cases, necrotizing pneumonia with cavity formation. Pulmonary resection may be necessary in patients who develop pneumothorax or empyema. Management options in complicated COVID-19 continue to evolve and should be individualized. Here, we present a case of Aspergillus empyema with refractory pleural fistula following COVID-19 pneumonia.
The patient was hospitalized in the intensive care unit for respiratory failure caused by COVID-19 pneumonia and developed a right pneumothorax 1 month after admission, with a halo sign in the middle lobe on computed tomography. Persistent massive air leakage and hypoxia developed, even with mechanical ventilation. Initially, to reduce the massive air leakage, endobronchial silicone spigot (endobronchial Watanabe spigot: EWS) were placed in the right B2 and middle lobe bronchi to stabilize the severe respiratory failure and septic shock. After EWS placement, the air leak decreased, with gradual improvement in the patient's multi-organ failure status. Subsequently, the patient underwent a right middle lobectomy and upper lobe wedge resection. Histopathology confirmed an active Aspergillus infection in the resected lung, and voriconazole was administered postoperatively. Air leakage persisted postoperatively, necessitating repeat surgery and, finally, thoracoplasty and negative pressure wound therapy. The patient was eventually discharged with home oxygen therapy.
This case illustrates the successful treatment of invasive pulmonary aspergillosis with refractory pulmonary fistula and empyema following COVID-19 pneumonia using a combination of endoscopic and surgical interventions. In cases of severe COVID-19 pneumonia, clinicians must remain vigilant for secondary infections, including aspergillosis. EWS placement can be effective in reducing significant air leakage and stabilizing patients' condition.
感染冠状病毒病（COVID-19）肺炎的患者中，约20%需要吸氧治疗；在这些患者中，约5%会进展为急性呼吸窘迫综合征，需要机械通气。COVID-19患者继发感染的发生率相对较低（细菌感染为16%，真菌感染为6.3%），但主要见于严重呼吸衰竭患者。COVID-19中的微血管损伤也可导致血栓形成，引起梗死，在某些情况下，还会导致坏死性肺炎伴空洞形成。对于发生气胸或脓胸的患者，可能需要进行肺切除术。复杂COVID-19的治疗方案不断发展，应个体化。在此，我们报告1例COVID-19肺炎后并发曲霉菌性脓胸伴难治性胸膜瘘的病例。
该患者因COVID-19肺炎导致呼吸衰竭入住重症监护病房，入院后第1个月出现右侧气胸，胸部计算机断层扫描显示中叶有晕征。即使进行机械通气，仍持续出现大量漏气和低氧血症。最初，为减少大量漏气，在右侧B2和中叶支气管置入支气管内硅胶插管（支气管内渡边插管：EWS），以稳定严重呼吸衰竭和感染性休克。置入EWS后，漏气减少，患者多器官功能衰竭状态逐渐改善。随后，患者接受了右中叶切除术和上叶楔形切除术。组织病理学证实切除的肺组织中有活跃的曲霉菌感染，术后给予伏立康唑治疗。术后仍持续漏气，需要再次手术，最终进行胸廓成形术和负压伤口治疗。患者最终在家中接受吸氧治疗出院。
本病例说明了采用内镜和手术干预相结合的方法成功治疗COVID-19肺炎后并发的侵袭性肺曲霉菌病伴难治性肺瘘和脓胸。在严重COVID-19肺炎病例中，临床医生必须警惕包括曲霉菌病在内的继发感染。置入EWS可有效减少大量漏气并稳定患者病情。
