Tracheal perforation and subcutaneous emphysema secondary to pseudomembranous invasive Aspergillus tracheobronchitis successfully managed with endotracheal tube manipulation

Introduction: Aspergillus is a ubiquitous fungus causing various pulmonary diseases depending on the host’s immune status. Aspergillus tracheobronchitis, a rare form of invasive aspergillosis, primarily affects severely immunocompromised or critically ill patients. We present the first known case of Aspergillus tracheobronchitis complicated by tracheal perforation and subcutaneous emphysema successfully treated with conservative endotracheal tube manipulation. Case description: A 64-year-old male with type 2 diabetes mellitus presented with generalized weakness and abdominal discomfort, later diagnosed with a perforated cecum requiring right colectomy. His postoperative course in the intensive care unit was complicated by septic shock, acute kidney injury, and failed extubation due to airway compromise. Seven days after the failed extubation, he developed subcutaneous emphysema in the neck. Chest computed tomography scan showed neck, left chest wall, and mediastinal emphysema. Bronchoscopy identified a focal black necrotic lesion on the left proximal tracheal wall and multiple small mucosal ulcerations throughout the proximal to distal trachea. The endotracheal tube was advanced beyond proximal tracheal necrotic lesion. Subcutaneous emphysema reduced overnight, suggesting that the lesion was the source of the air leak. Bronchial washings confirmed Aspergillus fumigatus, establishing a diagnosis of invasive Aspergillus tracheobronchitis. Treatment with voriconazole prevented further expansion of emphysema, which gradually resolved. Conclusion: Subcutaneous emphysema in ventilated patients with tracheobronchitis is a rare and challenging complication. This case demonstrates successful management through endotracheal tube manipulation to tamponade the lesion, highlighting subcutaneous emphysema as a potential manifestation of Aspergillus tracheobronchitis and offering a minimally invasive treatment approach.