We report the case of a five-year-old patient with a history of Fanconi's anemia from Neiva (Huila), who consulted for a clinical picture of four days of evolution with a mild fever of cough.
Background
The patient was the result of the first pregnancy of a 28-year-old mother; she was born at 36 weeks of gestation, with adequate weight and height for the gestational age, and without complications in the neonatal period.
At 14 months of age, she was diagnosed with Fanconi anemia and renal hypoplasia.
She had received multiple transfusions of packed red blood cells and platelets.
The last transfusion had been 10 days before admission reported.
Her past medical history showed that she was on a balanced diet, had a complete vaccination scheme, did not have mumps and did not have a family history of illness.
Diuresis and deposition were normal before admission.
The initial physical examination revealed a febrile, hydrated patient with no signs of respiratory distress.
Vital signs were as follows: heart rate, 163 per minute; respiratory rate, 32 per minute; temperature, 38.5 °C; oxygen saturation, 93 %; FiO2, 0.21; and weight, 10 kg.
The oral mucosa was moist and presented cutaneous dryness.
There were no signs of active mucosal bleeding and nasal secretion was scarce.
The patient presented soft palate petechiae as well as rhythmic cardiac noises, with a grade II/VI systolic murmur, and respiratory sounds without aggregates.
There was no pain in the abdomen and this was soft, without visceromegaly.
Distal perfusion was adequate and there were petechiae in the lower limbs.
On neurological examination, consciousness was normal and there was no focal neurological deficit.
Treatment with intravenous fluids was initiated and paraclinical tests were performed.
The hemogram showed: leukocytes, 1,010/μl; neutrophils, 9.9 % (100, absolute count); lymphocytes, 87.1 % (880, absolute count); hemoglobin, 6.3 g/dl; platelets, 17.7000.
Chest X-ray showed bilateral parahilar interstitial opacities without consolidation.
Because it was a febrile neutropenia, antibiotic treatment with cefepime was initiated before the sample collection for cultures.
A transfusion of packed red blood cells and irradiated platelets was performed.
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Escherichia coli was negative for ESBL and cefepime sensitive in the hemocultive, so the same management was continued.
At 48 hours after admission, the patient remained febrile, had persistent cough and respiratory distress, and required supplemental oxygen by nasal cannula.
Therefore, new studies were conducted and vancomycin was started.
A computed tomography (CT) of the thorax was taken, which revealed an image suggestive of a mass at the level of the left pulmonary hilium, not characterized, although possibly corresponding to the parenchyma, and a nodular lesion basal lateral lobe was initiated by administration of voriconazole.
Paranasal sinus CT was normal.
The result of the first antigen screening test performed was negative.
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Fiberoptic bronchoscopy with bronchoalveolar lavage revealed a whitish exophytic mass on the anterior wall of the right intermediate bronchus, about 4 mm in diameter, from which a biopsy sample was taken.
Bronchoalveolar lavage was performed at this level.
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Treatment was continued with broad-spectrum antibiotics.
At this time, immunoglobulins were within normal limits and three juice samples were negative, while the second test for detection of S. aureus in serum was positive, with 5.06 ng/mL.
A 45° hyaline partitioned hyaline hyaline hyphae was found in the cytology of broncholaveolar lavage, as in the biopsy material ; the culture of bronchoalveolar lavage was positive for the Aspergillus flavi complex.
Treatment with voriconazole was continued and the fever subsided.
On day 33 of voriconazole treatment, the patient again developed fever and hemodynamic instability, so treatment with meropenem was started; at six hours, the hemocultives were positive for Acinetobacter baumanii, and 24 hours after treatment.
