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] .