TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute respiratory distress syndrome (ARDS) caused by coronavirus disease (COVID-19) is known to predispose affected individuals to numerous secondary complications including bacterial superinfections. Less reported are the opportunistic fungal infections affecting a subset of patients lacking immunocompromising disease. COVID19-associated pulmonary aspergillosis (CAPA) is an underrecognized complication carrying high mortality in an otherwise healthy population. CASE PRESENTATION: A 55 year old male with history of obesity and type 2 diabetes mellitus presented to the hospital with a chief complaint of worsening dyspnea. In the ED, he was found to be afebrile, requiring high-flow nasal cannula and subsequently tested positive for COVID-19. The patient showed little improvement despite treatment with IV steroids, convalescent plasma, Remdesivir, and broad antibiotic coverage for suspected superimposed hospital acquired pneumonia. Chest CT without contrast on hospital day 23 revealed interval development of a complex cavitary lesion. HIV and Cryptococcus antigen were negative while QuantiFERON gold was intermediate. Follow-up testing with galactomannan returned elevated and the patient promptly initiated Voriconazole therapy for treatment of CAPA. The patient demonstrated marked clinical improvement and was discharged to a subacute rehabilitation center in stable condition on supplemental oxygen with plans for close monitoring of Voriconazole trough, galactomannan level and repeat chest imaging. DISCUSSION: Hallmarks of severe COVID-19 infection include ARDS, lymphopenia, systemic cytokine response and potential multiorgan failure often necessitating mechanical ventilatory support and ECMO in some cases. The manipulation and ultimate halt of the immunological cascade with the therapeutic agents, in combination with the direct viral damage to respiratory tract epithelium and eventual ciliary dysfunction, may in turn lead to complicated superinfections. Given the decreased use of diagnostic bronchoscopy to limit aerosolized exposure during the COVID-19 pandemic, clinicians have relied on less invasive means to diagnose CAPA including clinical, radiological and mycological criteria. CONCLUSIONS: COVID19 is a complex multiorgan process that descends on the patients with vastly varying clinical manifestations and progression. It is sagacious to raise awareness of the potential COVID19 has for co-infection with CAPA, as immunosuppressive drugs are the current strategy for treatment. Improved screening strategies can identify and enact early treatment of CAPA in critically ill patients who seem to clinically decline despite optimized supportive care. REFERENCE #1: Salmanton-Garcia, J., Sprute, R., Stemler, J., Bartoletti, M., Dupont, D., Valerio, M….Koehler, P. (2021). COVID-19–Associated Pulmonary Aspergillosis, March–August 2020. Emerging Infectious Diseases, 27(4), 1077-1086. https://doi.org/10.3201/eid2704.204895. REFERENCE #2: van Arkel, A., Rijpstra, T. A., Belderbos, H., van Wijngaarden, P., Verweij, P. E., & Bentvelsen, R. G. (2020). COVID-19-associated Pulmonary Aspergillosis. American journal of respiratory and critical care medicine, 202(1), 132–135. https://doi.org/10.1164/rccm.202004-1038LE REFERENCE #3: Machado, M., Valerio, M., Alvarez-Uria, A., Olmedo, M., Veintimilla, C., Padilla, B., De la Villa, S., Guinea, J., Escribano, P., Ruiz-Serrano, M. J., Reigadas, E., Alonso, R., Guerrero, J. E., Hortal, J., Bouza, E., Munoz, P., & COVID-19 Study Group (2021). Invasive pulmonary aspergillosis in the COVID-19 era: An expected new entity. Mycoses, 64(2), 132–143. https://doi.org/10.1111/myc.13213 DISCLOSURES: No relevant relationships by Muhammad Ehtesham, source=Web Response No relevant relationships by Dani Fribourg, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Bernadette Schmidt, source=Web Response