Survival After Invasive Pulmonary Aspergillosis in a Patient Requiring Sequential Veno-Arterial and Veno-Venous ECMO for Refractory Cardiorespiratory Failure: A Case Report
Edgar G. Moglia Ordaz*
Intensive Care Unit, Centro Médico Teknon, Quirónsalud, Barcelona, Spain.
*Corresponding Author: Edgar G. Moglia Ordaz, Intensive Care Unit, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain.
DOI: https://doi.org/10.58624/SVOAMR.2026.04.021
Received: August 06, 2026
Published: September 06, 2026
Citation: Moglia Ordaz EG. Survival After Invasive Pulmonary Aspergillosis in a Patient Requiring Sequential Veno-Arterial and Veno-Venous ECMO for Refractory Cardiorespiratory Failure: A Case Report. SVOA Medical Research 2026, 4:5, 184-189. doi: 10.58624/SVOAMR.2026.04.021
Abstract
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 a 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). Because of persistent severe respiratory failure despite appropriate antibacterial treatment, bronchoscopy with bronchoalveolar lavage was performed. BAL galactomannan was positive at an optical density index of 0.7, whereas serum galactomannan and fungal cultures were negative. In the clinical context, this finding supported a working diagnosis of pulmonary aspergillosis and prompted the initiation of voriconazole. The diagnosis was subsequently strengthened by the isolation of Aspergillus terreus from a repeat BAL culture at the referral center. 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: 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. The diagnostic utility of BAL galactomannan as an early marker, even when cultures are later positive for different species. That survival, while rare, is possible with aggressive, multidisciplinary management and prolonged antifungal therapy.
Keywords: Case report; invasive pulmonary aspergillosis; extracorporeal membrane oxygenation; acute respiratory distress syndrome; Aspergillus terreus; galactomannan; cytomegalovirus reactivation; therapeutic drug monitoring.