Female patient, 46 years old, with no morbid history.
chest pain, fever and coughing developed within one week.
He also reported a month of logical dysphagia, weight loss (seven kg) and night sweats.
A blood count showed hemoglobin 6.2 g/dl, leukocytes 9.830/mm3, platelets 77.200/mm3, CRP 216 mg/l and a chest X-ray showed consolidation in the right upper lobe.
The patient was hospitalized for investigation of bicites dysphagia and consumptive syndrome.
Bacterial pneumonia was diagnosed and she received ceftriaxone for 10 days, with good clinical response.
The dysphagia study included upper digestive endoscopy (UED) which showed three esophageal ulcers suggestive of viral etiology (cytomegalovirus) (CMV).
Biopsies were taken and treatment with ganciclovir for 10 days was initiated, with little clinical response.
Histological examination revealed mucosal erosion with no signs of CMV infection.
Blood PCR for CMV was also negative.
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Bicytic colitis was confirmed with a hemogram with neutropenia of 200 neutrophils/mm3; 88% blasts and an myelogram reporting acute myeloid leukemia (AML).
Once the antimicrobial treatments were completed, chemotherapy was initiated.
Three days after chemotherapy she presented an episode of febrile neutropenia (FN) with an ANC of 20 neutrophils/mm3.
A new chest X-ray showed no changes from the previous one.
Treatment with imipenem and IV vancomycin was started.
Due to persistent fever and neutropenia, cultures were repeated on the fourth day and lung, abdominal and pelvic CT was performed.
The pulmonary CT showed an infiltrate in the right upper lobe with "halo sign".
Voriconazole was started suspecting pulmonary aspergillosis.
Blood cultures and controls were negative.
Due to persistent dysphagia, a new UGE showed persistent esophageal ulcers.
The histological study showed septate hyphae, branched at 45°, suggesting Aspergillus spp.
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After two weeks of antifungal treatment, the patient was free of fever and without dysphagia.
Eighteen days of antibacterial treatment and 21 days of voriconazole were completed.
