1st Case Progression
The patient has now been hospitalized for seven days. Despite receiving antibiotics, steroids and inhaled bronchodilator, there is only a partial clinical improvement. The patient still has repeated fever spikes, requires oxygen therapy and suffers from intense night sweating. Repeated CBC reveals persistent leukocytosis (25.0 × 10⁹/L) and new onset of eosinophilia (26%, reference value: < 7%), CRP value of 58 mg/L with negative hemocultures, negative cultures from sputum, urine and rectum swabs.
In addition, vesiculopapular skin lesions begin to appear on the patient’s right arm and left cheek (Fig. 2a), however, both locations were previously in contact with a fixation tape (i.v. catheter and oxygen mask). Initially, the lesions appeared as red indurations, which eventually developed a white tip and coalesced. The dermatologist orders swabs of the lesion for various infectious etiologies (aerobic and anaerobic bacteria, viral and fungal pathogens), which are altogether negative, topical antibacterial treatment with Fusidic acid and corticosteroid cream was applied. In parallel, the result of PCR from the sputum sample came back positive for Aspergillus species antigen; however, both the Aspergillus antigen in serum and the sputum culture for Aspergillus were negative. In addition, a rheumatology consultation was requested to assess a possible vasculitis, as marked eosinophilia, vesiculopapular skin lesions, and respiratory insufficiency might be the symptoms of Eosinophilic Granulomatosis with Polyangiitis (EGPA). Due to these new findings and the alarming clinical state of the patient, a chest computed tomography (CT) scan was indicated, which showed an extensive interstitial lung process with marked mediastinal lymphadenopathy (Fig. 2b).