javascript:void(0)3rd Case Progression
Valganciclovir i.v. therapy has started, however, after five days, the patient showed little improvement. Fever spikes continued, along with night sweats. Repeated laboratory tests demonstrated a reduction of leukocytosis (17.0× 10⁹/L); on the other hand, the CRP remained unchanged (110 mg/L).
The rheumatology consultant recommended computed tomography positron emission tomography (PET-CT) and flow cytometry assessment of peripheral blood leukocytes to exclude hematopoietic malignancy. On the PET-CT, no extrapulmonary manifestation was evident, only isolated lung involvement was displayed, with multiple diffuse nodules in both lungs (Figure 4a). The flow cytometry screening was not suggestive of oncologic etiology.
Meanwhile, results of the skin and transbronchial biopsies became available. The transbronchial biopsy showed nonspecific inflammatory changes and no infectious agent was found (particularly focusing on CMV). Importantly, the skin biopsy revealed unspecific hyphae (Figure 4B), prompting us to reconsider the fungal etiology, although a secondary contamination might also be considered, according to the histopathologist. In a targeted query, the parents reported a short contact of the boy with mulch 24 hours before the development of the symptoms (he played with soil on an animal farm) and household molds exposure.
At this point, blood and BAL were sent for the pan-fungal antigen beta-D-glucan in further search for a fungal agent.