Review Article

Co-infection of Aspergillosis and Nasal Demodicosis in an Aplastic Anemia Patient with COVID-19: A Case Report

Mahsa Naeimi Eshkaleti^1,2, Alireza Abdollahi³, Mohammadreza Salehi⁴, Ali Ahmadi^1,2 and Sadegh Khodavaisy¹*

¹Department of Medical Parasitology and Mycology, Tehran University of Medical Sciences, Iran

²Students Scientific Research Center, Tehran University of Medical Sciences, Iran

³Department of Pathology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran

⁴Department of infectious diseases and Tropical Medicine, Tehran University of Medical Sciences, Iran

Submission: December 04, 2023; Published: January 31, 2024

*Corresponding author: Sadegh Khodavaisy, Ph.D, Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

How to cite this article: Mahsa Naeimi Eshkaleti, Alireza Abdollahi, Mohammadreza Salehi, Ali Ahmadi and Sadegh Khodavaisy. Co-infection of Aspergillosis and Nasal Demodicosis in an Aplastic Anemia Patient with COVID-19: A Case Report. Glob J Oto, 2024; 26 (4): 556192. DOI: 10.19080/GJO.2024.26.556192

Abstract

Demodex mites normally live in the pilosebaceous unit and gland, the presence of them can be harmless on the human skin. They are usually diagnosed in young adults or immunodeficiency states. We report a possible case of demodicosis in aplastic anemia patient with co-infection of aspergillosis and COVID-19. Direct microscopic examination of Sinus debridement was positive for both fungal elements as well as Demodex mites and they were diagnosed as Aspergillus flavus by sequencing and Demodex folliculorum respectively.

Keywords: Co-infection; Aspergillosis; Demodicosis; Aspergillus flavus; Demodex folliculorum

Introduction

Demodex is a genus of mites that normally live in the pilosebaceous unit and gland [1]. Two species live in humans: D. folliculorum and D. brevis [2]. Their presence can be harmless on the human skin and transmitted by skin-to-skin contact. Demodex mites are usually diagnosed in young adults or immunodeficiency states [3]. There are two types of demodicosis: primary and secondary demodicosis. Primary demodicosis could be the causative agent of pityriasis folliculorum, papulopustular, ocular and auricular demodicosis. Secondary demodicosis is usually related to systemic or local immuno-suppression and studies show increased severity of demodicosis [2]. For demodectic diagnosis, skin scraping from different regions like the nose, cheeks, chin, or forehead by direct examination or a skin biopsy under the microscopic examination. Demodicosis is diagnosed when there is a high density of Demodex mite (>5/cm2) in a 1cm2 area using a light microscope [3]. In this study, we demonstrate aplastic anemia, in a COVID-19 patient who simultaneously had D. folliculorum and Aspergillus flavus in his paranasal sinuses.

Case presentation

A 31-year-old male was a known case of aplastic anemia on a treatment of cyclosporine, was admitted with symptoms of high fever, dyspnea, and severe thrombocytopenia at the Imam Khomeini Hospital Complex, in June 2022. Due to the COVID-19 pandemic, a chest CT scan was done and ground glass opacities were seen (Figure 1). Real-time polymerase chain reaction (PCR) from nasopharyngeal swab was reported positive for SARS-CoV-2 and the patient took remdesivir (200mg/stat and 100mg/daily) and dexamethasone 8mg/daily for 5 days. The patient’s fever and dyspnea got better. After 5 days, she was discharged with a relatively good general condition. Three days later, he was referred with a fever of T: 38.6°C. The patient had hematuria in the early urination and had pain in the perianal area. A routine laboratory examination revealed pancytopenia and infection. Leukocytes (1.2×103/μl), Hemoglobin (7.6 g/dl), platelet (14×103/μl), erythrocyte sedimentation rate (106mm/hr.), and C- reactive protein (25mg/lit), other blood tests were within normal ranges.

Klebsiella pneumonia (sensitive: Meropenem and Amikacin, resistance: ceftriaxone, ciprofloxacin, co-trimoxazole) was isolated from blood culture, he also had hemoptysis. The patient was treated with meropenem (2 g/TDS/IV/Infusion). After one week, while the patient’s fever had stopped and her general condition had improved, he complained of facial pain and headache. Paranasal CT scan revealed pan sinusitis with bone destruction (Figure 2). Liposomal amphotericin B (350mg/daily/IV) was started. He also presented a lot of red papules and pustules surrounded by inflammatory redness and flushing in his trunk and limbs (Figure 3). The patient was referred for microscopic examination for Scabies, and the result was positive (Figure 4a). A potassium hydroxide 10 % of sinus debridement examination showed the presence of mite Figure 4(b) and fungal septate elements hyaline hyphae (Figure 4c).

Examination of the mite morphology (long striated posterior segment with four legs) and size (0.3-0.4mm long) detected it as D. folliculorum [4]. The sinus debridement was cultured on SDA for conventional and molecular methods at 37c and 25c for 4 weeks. Microscopic examination showed Aspergillus spp. For molecular identification DNA of Aspergillus spp. was extracted from SDA and purified. The entire internal transcribed spacer (ITS) region (ITS1-5.8S rDNA-ITS2) was amplified by PCR with the universal primers ITS1 (5’-TCC GTA GGT GAA CCT GCG G-3’) and ITS4 (5’- TCC TCC GCT TAT TGA TAT GC-3’). The PCR amplicon was sent for Sanger sequencing. Aspergillus flavus was identified using a basic local alignment search tool (BLAST) (http://www.ncbi.nlm.nih. gov/BLAST/) and the sequence was deposited into GenBank Data.

Discussion

Invasive aspergillosis was diagnosed in this immunocompromised person as he had aplastic anemia on a treatment of cyclosporine. Patients with aplastic anemia are the leading candidates for invasive fungal infections and invasive aspergillosis is among the most common infection in patients with hematological malignancy [5]. The diagnosis was confirmed by conventional and molecular methods from the sinus debridement sample and A. flavus was identified. The predisposing factors of invasive aspergillosis are commonly by species of A. fumigatus (about 80%), A. flavus (about 15-20%), and less common are A. terreus and A. niger. Although the majority (approximately 80%) of invasive aspergillosis is caused by A. fumigatus overall in the United States, A. flavus is the predominant pathogen in our study and tropical as well as sub-tropical areas like; most of the Middle East, southeast Asia and Africa. This pathogen can survive in dry conditions and higher temperatures, experimental in vivo studies in both normal and immunocompromised mice have shown more virulence of A. flavus compared to A. fumigatus [6-9]. The inability of host defenses in our pancytopenia patient predisposed the development of A. flavus and Demodex mites simultaneously in paranasal sinuses. For proliferation in the human body, Demodex mites need immunosuppression.

Studies showed severe demodicosis in immunocompromised patients with allogenic bone marrow transplant, stem cell transplantation, hematological malignancies, corticosteroid therapy [10,11] and scalp demodicosis in COVID-19 patient [12]. Even though the presence of D. follicullorum in debridement of the paranasal sinus increases suspicious rhino sinusitis due to the loss of patient, more investigation couldn’t be done to find out its pathogenic implementation. Apart from this probable role, a study has suspended mites in transferring the fungal spores into sinuses [13]. To the best of our knowledge, this is the first case of possible demodicosis associated with an aplastic anemia COVID-19 patient with a coinfection of invasive aspergillosis. In conclusion, this case shows more attention from clinicians and laboratory physicians about Demodex, especially in immunosuppressed patients. More studies are needed to investigate the role of aplastic anemia in the susceptibility of demodicosis.

Acknowledgments

This study has been funded and supported by the Tehran University of Medical Sciences (TUMS); Grant no. 1401-3-252- 63348.

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