Reporting a Case with Literature Review: Sunitinib Use for Metastatic Renal Cell Carcinoma Associated with Necrotizing Cavitary Pulmonary Aspergillosis with Aspergillus Flavus

Sunitinib associated chronic necrotizing cavitary pulmonary aspergillosis has rarely been reported in literature. This article describes a patient with biopsy proven papillary renal cell carcinoma initially treated by radical nephrectomy. He presented about 8 months later with progressively worsening abdominal pain, headache, weight loss of 40 pounds and investigation revealed extensive retroperitoneal and mediastinal lymphadenopathy with brain metastasis. He was evaluated by oncology and started on cycles of sunitinib with dexamethasone, which he took for about 6+ months. He presented to the hospital in respiratory distress requiring intubation and ICU admission and CT scan of thorax revealed a new large consolidation with necrosis and a cavity. Given suspicion of opportunistic fungal infection with sunitinib, he was started on empiric Vancomycin, Zosyn and Voriconazole. He underwent bronchoscopy, bronchoalveolar lavage and cultures revealed Aspergillus flavus. Subsequently serum and BAL (Bronchoalveolar Lavage) galactomannan were reported positive as well. Given poor prognosis, patient’s family elected for comfort measures. Enhanced clinical surveillance and implementation of prophylactic strategies based on risk stratification would aid in the prevention, early diagnosis and management of these infections.