darkhorse
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A 72-year-old man with non-Hodgkin's lymphoma, who is 10 days post chemotherapy, has persistent fevers. Of note, 3 days after his chemotherapy finished, he had a temperature of 38.5 C (101.3 F). He was started on ceftazadime and tobramycin. His fever resolved initially. However, now it is 7 days later and he again has similar temperature elevations. He has also developed some minimal hemoptysis. His blood pressure is 115/85 mm Hg, pulse 82/min, and respirations 20/min. Heart has a regular rhythm with no murmurs, lungs have some dry basilar crackles, abdomen is benign, and extremities have 1+ edema, but no erythema. Laboratory studies show a leukocyte count of 3,200mm3, hematocrit 28%, and platelets 18,000mm3. A chest x-ray shows development of some bilateral nodular densities. A CT scan of the lungs confirms multiple lung nodules, many of which have small hazy borders consistent with minimal perinodular hemorrhage. The most appropriate next step in management is to
A. add amphotericin B intravenous therapy to his current therapy
B. change the chemotherapy regimen due to treatment failure
C. continue the ceftazidime and tobramycin and give it time to work
D. refer the patient to radiation oncology for emergent bilateral
E. send him for a transesophageal echocardiogram
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| bax
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i think ans is A
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| neuroblastoma
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me to think so A.
Cuz ceftazadime and tobramycin already given before.. , now it seems fungal infection
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| darkhorse
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| darkhorse
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A. add amphotericin B intravenous therapy to his current therapy
Explanation:
The correct answer is A. In any post chemotherapy patient who has persistent fever despite appropriate broad-spectrum antibiotic coverage, fungal and resistant Gram-positive organisms need to be considered. This patient also has a chest CT scan showing multiple bilateral lung nodules with surrounding hemorrhage which is classic for invasive aspergillosis. The most effective current therapy is with amphotericin B. Continuing the ceftazadime and tobramycin (choice C) alone would not address the current problem.
The patient is presenting with an acute infectious process related to chemotherapy induced immune suppression. Although a lymphoma can involve the lung directly, it is not particularly common and does not fit this clinical scenario. This makes a treatment failure (choice B) incorrect. Bilateral lung irradiation is not something that is typically done in non-Hodgkin's lymphoma and certainly would not be an emergent procedure (choice D).
A transesophageal echocardiogram (choice E) can be used to look at vegetations on heart valves seen in endocarditis. If the vegetations are on the tricuspid or pulmonary valves, they can give off septic emboli to the lungs. This too can cause multiple lung nodules. However, they are often cavitary and do not show the perinodular hemorrhage that is classic for invasive aspergillosis.
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