Aspergillus tubingensis pneumonia with pulmonary oxalosis in a virologically suppressed person with HIV: A case report

Opportunistic aspergillosis has occasionally been reported in individuals with advanced HIV infection but remains rare overall and is particularly uncommon under well-controlled conditions. Here, we present a case of Aspergillus tubingensis pneumonia in a virologically suppressed person with HIV (PWH) in his late sixties. He was receiving bictegravir-based antiretroviral therapy, with a CD4 cell count of 368/μL and undetectable HIV RNA two months before symptom onset. His symptoms began with a cough, followed 20 days later by a fever and dyspnea, which required hospitalization. Computed tomography revealed bilateral pneumonia with a cavitary lesion in the right upper lobe. Voriconazole monotherapy failed, but subsequent combination therapy with voriconazole and micafungin resulted in partial clinical improvement. A. tubingensis was detected by polymerase chain reaction-based analysis followed by DNA sequencing, and antifungal susceptibility testing confirmed reduced susceptibility to multiple azoles. The patient developed pulmonary oxalosis as a complication. Following partial radiological improvement, he was discharged approximately five months later. Long-term oral voriconazole therapy was continued but was complicated by chronic respiratory insufficiency requiring home oxygen therapy. He ultimately died after 2.5 years of follow-up, and autopsy revealed extensive pulmonary fibrosis with traction bronchiectasis. Hyaline membrane formation was also observed in the lung parenchyma. This case highlights that Aspergillus tubingensis infection can occur in virologically suppressed people with HIV despite preserved CD4 cell counts and may result in substantial long-term pulmonary sequelae.