3  RESULTS
A 62‐year‐old woman was admitted to our ICU. She was intubated and developed severe ARDS with a Horowitz‐Index of 53 mm Hg. At the contrast‐enhanced CT a combination of emphysema, bilateral ground‐glass opacities with crazy paving and some peripheral nodular consolidations were seen (Video S1, patient #1, Figure 1A). Despite prone positioning, the patient required rescue veno‐venous extracorporeal membrane oxygenation (ECMO). PCR for SARS‐CoV‐2 and human metapneumovirus (hMPV) was positive in BALF. The patient developed severe intrapulmonary bleeding from the right main bronchus, which was stanched by cold lavages and instillation of tranexamic acid. BALF culture grew Aspergillus fumigatus, was positive for galactomannan, and intravenous voriconazole treatment was commenced.
FIGURE 1  Chest CT images of patients with COVID‐19 Associated Invasive Pulmonary Aspergillosis. A, Patient #1: Combined bilateral ground‐glass opacities with crazy paving and peripheral nodular consolidations. B, Patient #2: Ground‐glass opacities with small nodular infiltrations of up to 1 cm. C, Patient #3: Bilateral ground‐glass opacities diffuse nodular infiltrates and cystic cavities and partly air crescent sign. D, Patient #4: Bullous emphysema and ground‐glass opacities, interstitial changes and consolidations with nodular infiltrates. E, Patient #5: Ground‐glass opacities, smaller areas with crazy paving pattern, central and peripheral consolidations, and smaller nodular infiltrates A 70‐year‐old man was admitted to the ICU because of ARDS with a Horowitz‐Index of 93 mm Hg. PCR on BALF was tested positive for hMPV, SARS‐CoV‐2 and Aspergillus fumigatus. Two days before, serum galactomannan had turned positive. BALF was tested positive for galactomannan. Chest CT showed ground‐glass opacities with some small nodular infiltrations of up to 1 cm (Video S2, patient #2 Figure 1B). Due to acute renal failure requiring slow low‐efficient daily dialysis (SLEDD) and elevated liver enzymes, intravenous isavuconazole treatment was started.
A 54‐year‐old man presented with ARDS with a Horowitz‐Index of 128 mm Hg. TA revealed SARS‐CoV‐2 PCR positive and Aspergillus fumigatus in culture. BALF was positive for galactomannan. Chest CT showed bilateral ground‐glass opacities, diffuse nodular infiltrates and cystic cavities and partly air crescent sign (Video S3, patient #3 Figure 1C). Intravenous voriconazole treatment was initiated.
A 73‐year‐old man was transferred to the ICU due to ARDS with PCR on TA tested positive for SARS‐CoV‐2, and Aspergillus fumigatus that also grew in culture. Chest CT showed known bullous emphysema with ground‐glass opacities and consolidations with nodular infiltrates (Video S4, patient #4, Figure 1D). Intravenous voriconazole was begun.
A 54‐year‐old woman was transferred to the ICU due to ARDS with PCR on TA tested positive for SARS‐CoV‐2. Serum galactomannan returned positive in two consecutive serum samples. Chest CT showed bilateral ground‐glass opacities, smaller areas with crazy paving pattern, central and peripheral consolidations, and smaller nodular infiltrates (Video S5, patient #5, Figure 1E). Intravenous caspofungin was started. No autopsies were performed. Detailed patient characteristics are given in Table 1.