Survival after Invasive Pulmonary Aspergillosis in a patient requiring sequential Veno- Arterial and Veno-Venous ECMO for refractory cardiorespiratory failure: a case report

Background Invasive Pulmonary Aspergillosis (IPA) in critically ill patients on Extracorporeal Membrane Oxygenation (ECMO) is a highly lethal condition, with mortality reported over 80%. Diagnosing and managing this condition is complicated by underlying severe illness, non-specific findings, and profound acquired immune dysfunction. Case Presentation: We report the case of a 67-year-old female with no prior immunosuppression who survived a catastrophic 3-month ICU stay. She initially suffered an cardiac tamponade requiring surgical repair, which was complicated by a massive pulmonary embolism (PE) necessitating Veno-Arterial ECMO (VA-ECMO) and mechanical thrombectomy. After weaning from VA-ECMO, she developed severe ARDS from an E. coli ESBL pneumonia, requiring initiation of Veno-Venous ECMO (VV-ECMO). Her failure to improve led to a bronchoscopy, which was positive for Galactomannan antigen (index 0.7), prompting initiation of voriconazole for probable IPA. After 33 days, she was transferred to a referral center (Hospital Clínic), where VV-ECMO was weaned. However, she relapsed with severe respiratory failure. A new bronchoscopy confirmed invasive aspergillosis via culture of Aspergillus terreus and revealed high-load Cytomegalovirus (CMV) reactivation (240,000 copies/mL). She was successfully treated with a prolonged 7-week course of isavuconazole and ganciclovir. Her recovery was protracted, complicated by gastrointestinal bleeding and severe critical illness myopathy, but she was eventually weaned from all organ support and discharged to rehabilitation. Conclusions This case of survival highlights the extreme complexity of managing severe ARDS on ECMO. It underscores: (1) The importance of proactive investigation for fungal and viral superinfections, such as Aspergillus and CMV, in patients with ARDS who fail to improve, as this indicates profound acquired immunoparalysis. (2) The diagnostic utility of BAL galactomannan as an early marker, even when cultures are later positive for different species. (3) That survival, while rare, is possible with aggressive, multidisciplinary management and prolonged antifungal therapy.