Marked cachexia in probable invasive pulmonary aspergillosis with bronchopleural fistula

A 49-year-old man with a medical history of diabetes and heavy smoking was admitted to intensive care with severe bilateral pneumonia associated with marked cachexia. He developed a complex right-sided bronchopleural fistula and was transferred to our tertiary centre for consideration of surgical intervention. Despite escalation of antibiotic therapy, he did not improve and further investigations led to a diagnosis of invasive pulmonary aspergillosis. Definitive treatment plans required a right pneumonectomy; however, given the severity of cachexia, he remained unable to undergo such a large operation. This case demonstrates an atypical presentation of invasive pulmonary aspergillosis in a mildly immunodeficient individual. It highlights the challenges in assessment and management of critically ill patients’ nutrition as well as optimal timing for surgical intervention.