A 38-year-old woman with a history of 8 months of polyarthralgia, malar rash and general malaise, associated with rapidly progressive renal failure.
Systemic lupus erythematosus (SLE) was diagnosed and treatment with methylprednisolone 3 g was initiated, followed by cycles of midazolam 500 mg 2 cycles, after which she developed acute pyelonephritis due to E. coli and diarrhea.
Given the persistent deterioration of renal function associated with anasarca, renal replacement therapy was initiated and treated at our institution.
Klebsiella pneumoniae was isolated 48 hours after admission due to severe septic shock associated with distal necrosis of the upper and lower limbs. Noradrenaline was required up to 5 u/kg/min due to a new microbiological diagnosis of diarrhea.
Computed tomography (CT) of the chest, abdomen and pelvis revealed foci of condensation of the lower lobes, mild pericardial and left pleural effusion and pancolitis of probable infectious inflammatory etiology.
It was associated with a slow decrease in vasoactive drugs and partial response to antibiotic and antiviral therapies.
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After 10 days, fever, hemodynamic deterioration, elevated inflammatory parameters reappeared, highlighting severe bronchial obstruction.
A new CT scan showed multiple areas of bilateral alveolar filling, with peripheral parenchymal opacities in “emerged glass” density, as well as moderate colonic thickening and ascites.
The study was complemented with fibrobronchoscopy (FBC), bronchial tree up to segmental level with erythematous mucosa, presence of multiple ulcers with fibrinous bottom and extremely friable tissue.
Bronchoalveolar lavage (BAL) was performed, obtaining calcofluor staining (+) to septate hyphae, culture (+) to Aspergillus fumigatus in 9.1, with plasmatic index of 10, 1.
Catechin and voriconazole were started and adjusted for renal function.
1.
The patient presented with respiratory failure secondary to severe bronchial obstruction, requiring new control and cleaning CBF, in which persistence of severe bronchial involvement with detachment of the mucosa into the endocanal space was observed.
A bronchial biopsy was performed, which showed extensive necrosis and fibrinous exudate tissue, with PAS stains and Gro compatible endoleaks with philosophic and yeast elements.
Given the alteration in liver tests with cholestatic pattern, adverse drug reaction was diagnosed and a change from voriconazole to liposomal amphotericin was decided after 15 days of treatment.
The patient subsequently became torpid, with hemodynamic instability and new infectious complications despite wide antibiotic, antifungal and antiviral coverage, and died 55 days after admission to our institution.
