Investigations
A comprehensive workup of acute myocarditis conducted included viral
infection, Mycoplasma pneumoniae infection, and toxin
screening. All test results were negative. Additionally, an
endomyocardial biopsy was performed, and the pathological findings
revealed mild interstitial fibrosis and no pathological evidence of
acute myocarditis (Figure 3).
Further investigation for persistent infiltration in the right middle
lung zone was performed. A chest CT scan could not be performed due to
the unstable condition and mechanical circulatory support. As an
alternative, a lateral plain chest X-ray was done, which indicated a
suspected lesion in the superior segment of the right lower lobe (RLL).
The finding of bronchoalveolar lavage (BAL) through fiberoptic
bronchoscopy was old blood streak with mild mucosal swelling at distal
right bronchus intermedius (Figure 4). Separate BAL samples were
collected from the superior segment and posterior segment of the RLL and
were sent for aerobe culture, cryptococcal antigen, andAspergillus galactomannan antigen. The aerobe culture of the BAL
fluid showed Trichosporon asahii and
trimethoprim-sulfamethoxazole resistant Stenotrophomonas
maltophilia . Additionally, the Aspergillus galactomannan antigen
and cryptococcal antigen test were positive from BAL fluid from the
superior segment of the RLL. Upon discussing the result of the BAL fluid
cryptococcal antigen, an additional serum cryptococcal antigen test was
performed which came back negative. This raised suspicion of a false
positive cryptococcal antigen due to cross-reaction withTrichosporon asahii . [7] Considering the overall test results, the
patient was diagnosed with probable invasive pulmonary aspergillosis
(IPA) in conjunction with Stenotrophomonas maltophiliaventilator-associated pneumonia (VAP).