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).