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.