A 23-year-old man, with no known morbid history, presented to the Emergency Unit with 15 days of progressive asthenia, myalgia, cough and chills.
On physical examination numerous herpetiform lesions stand out in the palate, hemogram shows pancit, so it is decided to hospitalize.
Myelogram, immunophenotype and karyogram were performed, and the diagnosis was undifferentiated LMA with CD7 expression.
Induction chemotherapy was initiated with a 3+7 scheme (daunorubicin + cytarabine) presenting diarrhea and fever on the fourth day of the first cycle, so broad spectrum hemocultives were taken and empirical antibiotic therapy was initiated.
The hemocultives were positive for Klebsiella pneumoniae resistant to third generation cephalosporins, maintaining the initial antibiotic treatment.
The patient remains febrile without symptoms suggesting the source of infection; she has severe neutropenia lasting for 20 days, with rising inflammatory parameters and alteration of liver tests with cholestatic pattern.
It was decided to add empirical antifungal treatment with anidulaline and a computed tomography (CT) of the chest, abdomen and pelvis was requested, in which hepatocyte inflammation is highlighted splenic focal lesions suggestive of infectious diseases.
He also had left chorioretinitis with a red background suggestive of mycosis.
Voriconazole (as Sabourand Medium) treatment was performed with negative results. MALDI TOF MS (Matrix-Assisted Laser Desorption/Ionization time of h capita with mass spectrometry) was performed.
Due to lack of response to therapy, anidulaline is replaced by liposomal amphotericin B (50 mg/day), echocardiography is performed to rule out endocarditis.
Nine CT scans showed multiple ground glass areas in both upper and middle lobes, bivascular atelectasis and pleural effusion left moderate liver, mediastinal lymphadenopathy and bilateral focal hyliar.
Catheter cultures were all negative.
Sepsis was performed evacuating fluid with pleural study showing exudate predominantly mononuclear.
The patient developed disabling pain in the left hypochondrium and flank, so radiological control was performed showing regression of liver and kidney lesions, but increased left pleural effusion and splenic lesions.
A multidisciplinary analysis of the case led to the decision to perform conservative treatment for evacuation and pleural effusion, and to define the differential diagnosis (neoplastic, tuberculous and invasive mycosis).
CTV was performed with evacuation of 2,000 ml of pleural effusion, followed by saline solution, pleural biopsy and diaphragmatic drainage. The exploration revealed multiple lesions of approximately 4 mm diffusely distributed parietal, visceral and diaphragmatic.
The patient underwent laparotomy and hemorrhagic splenic enlargement plus splenic abscess. A cystectomy was performed to clean the focus.
In the histological study of the samples taken during CTV and laparotomy, septate hyphae were observed.
Intraoperative cultures were positive for S. capitata at 72 h.
After surgery, the patient evolved favorably and 58 days of treatment with liposomal amphotericin B were completed (accumulating a dose of 2.9 g without adverse effects) and 80 days with voriconazole (cumulative dose of 32).
She is discharged in good condition, ending the oncological treatment remaining during cycles of chemotherapy with voriconazole prophylaxis.
At more than 2 years of follow-up the patient has no evidence of disease.
