A 29-year-old man was with no medical history admitted 14 h later with multiple flame burns all over his body in a bushfire. About 7% of the body surface area (BSA) on his whole body except the front of the torso were normal skin, and the remaining 93% were burn wounds. He was admitted to the ICU of the local hospital and received treatment including tracheotomy, anti-infection and anti-shock with fluid rehydration. The patient was in a critical condition and transferred to the ICU of our hospital by ambulance for further treatment. Physical examination of the patient upon admission: body temperature 36.5℃, breathing 24 times /min, pulse 140 times /min, blood pressure 105/51 mmHg. The patient's consciousness was blurred, the breathing sound in both lungs was clear, and dry and wet rales were not heard. About 1% BSA lesions were seen in the right temporal part of the head of the body and 2% BSA lesions were seen in the dorsal part of the feet. The lesions were red and white, and the other wounds were dry scab like changes. Laboratory results showed that WBC 14.64×109/L, RBC 5.31×1012/L, HGB 169g/L, HCT 51.5%, PLT144×109/L, ALT 149 U/L, AST 428U/L, TP44.3g/L, ALB29.2g/L, GLO 15.1g/L, CK 24125U/L, CK-MB 150 U/L, MB 13160ng/L, BUN 8.41 mmol/L, CRE 136µmol/L, K + 6.1mmol/L, Na + 143.9mmol/L, Cl 114mmol/L, APTT 97.2S, PT 20.8S, TT 19.7S. Admission diagnosis: 1. Large systemic burns (TBSA 93%: deep II° burns 3%, III° burns 90%, particularly severe), wound infection infectious shock; 2. Inhalation injury after tracheostomy(moderate); 3. Multiple organ insufficiency: acute kidney injury, acute liver injury, traumatic coagulation dysfunction; 4. Rhabdomyolysis.
After admission, the patient was treated with anti-shock, anti-infection, sedation and analgesia, ventilator and respiratory support, nutritional support, continuous blood purification, and wound treatment. From 2022-10-22 to 2022-10-26, intravenous infusion of meropenem (MEPM) 1g Q6h+ vancomycin 1g Q12h was given. In the later period, sensitive antibiotics were selected for anti-infection treatment based on the pathogen of wound culture and drug susceptibility test results. The patient's bronchoscopy on 2022-10-22 showed airway congestion above the bulge, without significant erosion, and no abnormal changes of bronchus and branches in each lobe were reported. Then on 2022-10-28, the bronchoscopy results showed slight hyperemia of trachea and bilateral left and right main bronchial mucosa without edema or bleeding; white ring ulceration was observed in the opening of the basal branch of the outer basal section of the left lower lobe (Fig. 1a); the surrounding airway mucosa was smooth without congestion, edema or erosion, and no obvious secretions. Considering the possibility of Aspergillus infection, In addition to VRCZ 300mg Q12h antifungal treatment (400mg q12h on the first day) and local amphotericin B atomization treatment, Aspergillus was cultured in airway lavage fluid specimens on that day, and the result of galactomannan (GM) test was 1.256. Then the bronchoscopy on 2022-11-3 showed that the bronchial ulcer was deepened and increased (Fig. 1b). Filamentous fungi, carbapenem-resistant Klebsiella pneumoniae (MEPM mic value 4mg/dL) were cultured in alveolar lavage fluid on 2022-11-08. So the dose of MEPM was increased to 1g q4h. Next on 2022-11-10, the bronchoscopy showed a smaller area of bronchial ulcer (Fig. 1c). The histopathological findings of biopsy specimens showed excessive necrosis, fungal mycelia and spores, and the morphology was inclined to Aspergillus (Fig. 2a, b). Dynamic fiberoptic review showed that the left lower lobe bronchial ulcer gradually shrank (Fig. 1d, e), and no Aspergillus was cultured after airway lavage fluid culture after November 15, and GM test turned negative. Finally, 22 days after discontinuation of antifungal therapy, bronchoscopic images showed that the white scars had basically disappeared (Fig. 1f). During the whole hospitalization, the immune function examination of the patient was generally normal, and the lung ventilation and ventilation function were normal. The lung image and the right lower lung exudation had double lower lung drop changes, which improved after enhanced postural drainage (Fig. 3). According to the guidelines of Infectious Diseases Society and European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) [4], the mycological evidence met the criteria for IPA. The diagnosis of IATB was established.