Extracorporeal membrane oxygenation therapy for severe influenza-associated pulmonary aspergillosis: a case report

Background Influenza-associated pulmonary aspergillosis (IAPA) is an increasingly recognized life-threatening condition in non-classically immunocompromised hosts. This report describes the clinical course and management of severe IAPA involving significant airway invasion. Case description A 34-year-old female presented with a 1-week history of fever and rapidly progressive dyspnea. Laboratory testing confirmed influenza A (H1N1) infection and significantly elevated serum galactomannan (GM) index 5.436. Despite invasive mechanical ventilation, the patient developed refractory acute respiratory failure (ARF) characterized by extreme airway resistance ( 190 cmH 2 O/L/s ) and extensive subcutaneous emphysema. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated as a bridge to facilitate diagnostic bronchoscopy, which revealed extensive necrotic pseudomembrane. Subsequent BALF microscopy and mNGS confirmed Aspergillus fumigatus coinfection with Influenza A (H1N1), establishing the diagnosis of IAPA. Management involved a combination of systemic and localized bronchoscopic antifungal therapy (Amphotericin B) and iterative airway clearance. Despite complications including secondary extensively drug-resistant Pseudomonas aeruginosa infection and suspected drug-induced hemolysis, the patient was successfully weaned from ECMO on 22 March 2023 and eventually discharged following clinical improvement. Conclusion VV-ECMO combined with repeated bronchoscopic interventions can serve as a rescue strategy in selected patients with airway-invasive IAPA and refractory respiratory failure.