Case Presentation: A 52-year-old unvaccinated male with past medical history of asthma and uncontrolled obstructive sleep apnea presented to the ED ten days after receiving a diagnosis of COVID-19 with worsening dyspnea. He endorsed a cough, fever, chills, and non-bloody diarrhea, and denied chest pain, leg edema, and anosmia. His initial vitals were remarkable for an oxygen saturation of 65%. A CBC demonstrated leukopenia consistent with COVID-19 infection. Blood labs showed hyperglycemia (blood sugar 182 mg/dL, hemoglobin A1c 9.6%). On physical exam, scattered bilateral crackles were noted. He was placed on high-flow nasal cannula (HFNC) immediately due to critical hypoxemia. CT PE was negative, and CXR revealed multifocal, bilateral opacities consistent with COVID-19 pneumonia. He was started on dexamethasone and remdesivir and admitted to the MICU for increasing oxygen needs and acute hypoxemic respiratory failure. Notably, the patient had no known diagnosis of diabetes mellitus. As a result, he was also started on sliding scale insulin and Lantus.In the MICU, barcitinib was also added. Linezolid and cefepime were added for fear of a bacterial superinfection, but were discontinued after receiving negative blood and sputum cultures. He was transferred out of the MICU four days later after successful weaning of his oxygen but soon returned to the MICU due to worsening oxygen needs. New leukocytosis prompted a repeat respiratory culture, which grew mold on a preliminary read. As a result, voriconazole was initiated due to concern for Aspergillus infection. This antifungal was continued upon confirmation of Aspergillus fumigatus growth on final reading. A repeat CT, negative for PE, revealed left pneumomediastinum, small right apical pneumothorax with associated subcutaneous emphysema, and worsening bilateral opacities. Despite ongoing treatment, the patient still required NC at rest and HFNC with minimal exertion. He remains hospitalized with plans to discharge with HFNC at home.

Discussion: CAPA is a result of opportunistic fungal infection, causing devastating disease in immunocompromised patients. A crucial risk factor to be aware of is the use of high-dose corticosteroids for a prolonged period of time [1]. The diagnosis of CAPA is based on a combination of imaging, microbiology, and clinical presentation [2]. Peripheral nodules, air crescent, reverse halo sign, nodular consolidation, ground-glass opacities, crazy paving pattern, pleural effusion, and pulmonary cysts have been reported among patients with CAPA [3]. A fungal culture and galactomannan test from respiratory specimens can assist in early diagnosis. The usual presenting symptoms of CAPA include refractory fever, pleural rub, chest pain, or hemoptysis. Voriconazole should be initiated immediately upon diagnosis as it is a first-line anti-Aspergillus agent [3].

Conclusions: The clinical presentation of CAPA is often subtle, but is associated with high morbidity and mortality. Multiple reports add support to our observation that CAPA can be attributed to worsening COVID-19 pneumonia. Early diagnosis and treatment is vital to prevent worse clinical outcomes. Therefore, physicians should demonstrate heightened awareness for risk of developing CAPA in critically ill COVID-19 patients. Additionally, clinicians should exercise a low threshold to promptly identify and treat CAPA, especially in patients taking high-dose corticosteroids for prolonged periods.