Methods
Laboratory testing were as follows: white blood cell (WBC) of 1100/mm3, polymorphonuclear neutrophils (PMN) of 400/mm3, hemoglobin of 7 g/dl, platelets (PLT) of 91000/mm 3 and C-reactive protein (CRP) of 15 mg/dL.Figure 1 revealed the neutrophil trend during the chemotherapy.
Considering patient’s febrile neutropenia and dry cough, chest High-resolution computed tomography (HRCT) and paranasal sinuses CT scan (CT PNS) were performed which revealed multiple peripheral and central nodular opacities and sinusitis respectively [Figure 2, 3] . According to nodular pneumonia and sinusitis with febrile neutropenia, prophylactic antibiotics were discontinued and treatment with meropenem 1gr IV every 8 hours, ciprofloxacin 400 mg every IV every 8 hours, vancomycin 1 gr IV every 12 hours, and liposomal amphotericin B (5mg/kg) 350 mg IV daily were initiated.
Nucleic acid amplification test for influenza A and B and Real-time reverse-transcriptase–polymerase-chain-reaction (rRT-PCR) for SARS-CoV-2 were negative. Blood cultures and serum galactomannan antigen test with Platelia Aspergillus ELISA kit (Bio-Rad) were reported negative (0.3).
According to sinusitis and pneumonia with nodular pattern the patient underwent bronchoscopy with bronchoalveolar lavage (BAL). The sample was sent for bacterial and fungal smear and culture, and also galactomannan. The culture of BAL revealed colonies consistent with Mucoraceae species [Figure 4] . The BAL galactomannan antigen test with Platelia Aspergillus ELISA kit (Bio-Rad) was reported 3.8 index which was high. Cytopathology testing for malignancy was negative.
In addition according to sinuses endoscopy which showed scattered areas of pale, necrotic tissue concerning for invasive fungal sinusitis, the patient underwent functional endoscopic sinus surgery (FESS) and the sample sent for smear, culture and histopathological evaluation. The culture revealed colonies consistent with Aspergillus flavus [Figure 5] . The histopathologic evaluation showed extensive necrosis with invasive broad aseptated hyphae compatible of invasive mucormycosis [Figure 6] .