| A |
guangyu, multani001, vijay1900 |
3 |
23% |
| B |
fd, cool doctor, lq2006, CocaCola, inkspot, milestogo, khiladi, ansalshah, Justice |
9 |
69% |
| C |
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0 |
0% |
| D |
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0 |
0% |
| Author | 5 Posts |
Justice
Forum Fanatic
Topics: 101
Posts: 1,969
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Please vote with your answer
A 52-year-old woman from Kentucky has acute myeloid leukemia. After several cycles of induction chemotherapy and subsequent relapse, she undergoes matched unrelated allogeneic stem cell transplantation. Her course is complicated by Pseudomonas pneumonia and Clostridium difficile colitis prior to engraftment, acute graft-versus-host disease treated with corticosteroids and tacrolimus, and Staphylococcus aureus catheter-related bacteremia. By day 80 after transplant, chronic graft-versus-host disease is documented by biopsies of the gastrointestinal tract and skin, and high-dose corticosteroids are begun.
On day 90, she develops fever to 38.9 °C (102.0 °F), pleuritic chest pain, cough, and hemoptysis. A chest radiograph shows a right lower lobe pulmonary infiltrate. A high-resolution CT scan of the chest is shown.
Vancomycin and cefepime are begun.
Which of the following should be done next?
A. Remove the central venous catheter
B. Begin amphotericin B
C. Begin fluconazole
D. Begin azithromycin
Attached Files:
Scan.doc (149 KB, 27 downloads)
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| aspire
Forum Senior
Topics: 24
Posts: 158
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A?
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| CocaCola
Forum Guru
Topics: 35
Posts: 908
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b - immunocomprised patient w/ a fungal ball from aspergillosis - needs amphotericin B
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| inkspot
Forum Guru
Topics: 26
Posts: 559
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yeah i thought the same cocacola
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| Justice
Forum Fanatic
Topics: 101
Posts: 1,969
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The correct answer is B
This woman has symptoms strongly suggesting invasive pulmonary aspergillosis for which amphotericin B is indicated. Her risk factors include leukemia, hematopoietic stem cell transplantation, prior neutropenia, prior use of broad-spectrum antibiotics for bacterial infections, and, most importantly, chronic graft-versus-host disease treated with high-dose corticosteroids. Recent data suggest that most transplant recipients with invasive aspergillosis do not develop infection in the pre-engraftment phase; instead, infection occurs when they develop graft-versus-host disease that is treated with high-dose corticosteroid therapy.
High-resolution CT scanning frequently allows visualization of multiple pulmonary nodules that are not seen on chest radiographs. Scans also frequently show a pulmonary infiltrate with a “ground-glass” appearance around the nodule, termed a halo sign. The halo sign indicates bleeding and is characteristic of changes induced by angioinvasive fungi, such asAspergillus. High-resolution CT scanning of the chest should be followed by bronchoscopy to identify the exact etiologic agent, since several angioinvasive fungi have the same clinical and radiologic features.
The patient’s presentation is not typical of a catheter-related infection; therefore, the central venous catheter should not be removed. Fluconazole is not effective for aspergillosis, and there is a high likelihood that the patient was, and may still be, on fluconazole prophylaxis. Atypical pneumonia such as Legionnaires’ disease is not usually associated with hemoptysis. Therefore, azithromycin is not indicated.
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