Unexpected fungal aortitis leading to aortopulmonary fistula: an autopsy case

Abstract

  We present a possibly unique autopsy case of fatal aortopulmonary fistula associated with subclinical infectious aortitis in an elderly man. After 6-week antifungal therapy for candidiasis in his eyes accompanying leakage from anastomoses following gastrectomy, β-D-glucan levels remained elevated despite negative blood cultures. Six weeks after completion of the antifungal therapy, he was re-hospitalized for hematochezia possibly due to bleeding associated with the anastomosis sites, and arterial embolization was successfully performed. However, about three weeks after the embolization, he died of hemorrhagic shock due to sudden bloody “vomiting”. Autopsy revealed no anastomosis-related bleeding but an unexpected non-aneurysmal Candidal aortitis-related aortopulmonary fistula. This had caused massive fatal hemorrhage into the lung parenchyma and resultant bloody “vomiting”. We believe that the long-standing elevated β-D-glucan level, even with negative blood culture results, may indicate subclinical fungal aortitis. This may have directly contributed to our patient’s death, although such a fatal event may be rare.