An 8-year-old male patient who had undergone surgery for ischemic peritonitis at least six months before, whose histology showed an appendix with a punctiform perforation in his distal third, with no other relevant morbid history.
She was admitted to her hospital of origin with progressive periumbilical pain and 3 days of evolution, bilious vomiting, fever 39oC, anorexia and general malaise. The symptoms were interpreted as complicated intestinal obstruction and secondary septic shock.
During surgery, obstruction by adhesions with perforation and necrosis of the distal ileum and secondary peritonitis were demonstrated, performing an ileal resection of 20 cm and contained laparotomy.
On the third postoperative day, the patient was referred to our hospital due to persistent anuria and required renal replacement therapy.
Upon admission, the patient was in septic shock requiring vasoactive epinephrine.
He was immediately admitted to hospital with continuous venous catheter and invasive monitoring, antibiotic therapy with ampicillin, cefoxime and metronidazole, and total parenteral nutrition.
After 24 hours, exploratory laparotomy was performed, clean, remaining again with contained laparotomy.
In a re-exploration the following day, 10 cm of necrotic ileum was resected.
He required insulin infusion therapy for seven days at a dose of 0.02-0.03 U/kg/h for sustained hyperglycemia above 200 mg/dl. After one week, hemodynamic stabilization was achieved and vasoactive support was suspended.
He remained on mechanical ventilation with minimal parameters for the management of his contained laparotomy, being asymptomatic respiratory and persisting in anuria.
On the ninth day the laparotomy was closed; however, the ileostomy presented necrotic appearance with a green color, whose culture was positive for A. fumigatus.
Two days later, it was decided to perform bronchoalveolar lavage due to purulent bronchial secretions and the appearance of pulmonary nodules, from which culture was also isolated A. fumigatus.
The mycological diagnosis was later certified in the Laboratory of Midwifery of the Microbiology and Midwifery Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile.
Antifungal therapy was started with deoxycholate B (1 mg/kg/day) and voriconazole (load: 25 mg/kg ev. tracheal cultures; subsequent amphotericin ossotomy was negative in 7 mg/kg/day).
Quantification of serum immunoglobulins was within normal range and ELISA test for HIV was negative.
In the following days, anuria persisted and fever persisted, despite the use of the drainage scheme continued abdominal wall TAC (with normal abdomen).
Antibiotic therapy was empirically extended with imipenem.
In the third case, the patient presented hemodynamic instability, increased waist circumference and evidence of ARDS and septic shock. Due to the progressive abdominal wall defect, the patient was surgically exploded in the ICU due to the patient's condition.
In the following hours, there was marked hemodynamic and ventilatory deterioration, refractory to vasoactive amines, dying on the 24th day of hospitalization.
A manpower control test taken the day before death was negative.
He completed a total of 15 days with amphotericin B and voriconazole.
1.
The anatomopathological study revealed the presence of characteristic hyphae of Aspergillus sp within several parenchyma, with vascular invasion: encephalon, lung, heart, digestive tract, pancreas, liver and kidneys compatible with systemic aspergillosis, which
