SCT Question 9
Publication/Presentation Date
7-2023
Published In/Presented At
Question 9
A 62-year-old refractory AML patient with prolonged pancytopenia was transplanted with a HLA matched unrelated donor in first complete remission with incomplete count recovery. Day 60 evaluation showed a normocellular marrow with 100% donor chimerism. He presents on day 82 with persistent cough for the last ten days and progressive left sided pleuritic chest pain. Current prophylaxis includes tacrolimus, voriconazole, atovaquone and high-dose valacyclovir (D-CMV+/R-CMV-). The patient does not appear toxic and is not in distress. HR and blood pressure, respiratory rate as well as SaO2 are normal. There is a low-grade fever. Lung auscultation is normal, and so is respiratory effort. Non contrast CT of the chest demonstrates a peripheral region of dense consolidation in the LUL with surrounding ground glass opacification. The patient is admitted to the hospital, broad spectrum antibiotics are started after cultures, BAL is performed and
The most likely, eventually successful therapy will be
- IV Zosyn+Vancomycin
- IV Posaconazole
- Ganciclovir
- VATS and liposomal amphotericin B
- IV Bactrim
Answer
Option 4. This patient had a prolonged period of cytopenia, predating the transplant which puts him at risk for invasive fungal infection (IFI). Appropriately, he is on voriconazole for prophylaxis, but on occasion in high risk patients one may observe a breakthrough IFI with a resistant fungal organism such has mucor, Rhizopus and fusarium are the most common organisms encountered and carry a high mortality. They are difficult to diagnose by conventional means, requiring biopsies to get tissue. Recently cell free microbial DNA sequencing techniques, such as those used in Karius testing have made the diagnosis a little faster. Conventionally, surgical resection of heavily involved foci, as well as a broad-spectrum antifungal such as Ambisome and or Posaconazole are effective, but only with adequate debridement of infected tissue. Pain suggests angioinvasion and pleural inflammation.
Disciplines
Medicine and Health Sciences
Department(s)
Department of Medicine
Document Type
Research