We report the case of a 2-year-old female patient diagnosed with L1 ALL treated with prednisone and chemotherapy.
After her first cycle of induction chemotherapy she was admitted for an episode of high-risk febrile neutropenia (HRNF), with no evident clinical focus, highlighting the presence of oral mucositis on physical examination.
Antimicrobial treatment was initiated with ceftazidime, amikacin and cloxacillin.
A positive blood culture for Staphylococcus warneri susceptible to oxacillin was collected and interpreted as contamination.
Febrile fever and nasal discharge 48 hours after admission showed conjunctival secretion (with bacterial culture and negative PCR for adenovirus) associated with an increase in preserved volume in the right eye with epistaxis.
On the fourth day of evolution of NFAR, due to an unfavorable evolution (persistence of fever and rising C-reactive protein (CRP) (132 mg/L), antimicrobial treatment was changed to vancomycin and piperacillin.
Computed axial tomography (CAT) of the paranasal sinuses revealed maxillary sinusitis and right etham, without orbital involvement.
Chest CT, abdominal ultrasound and eye fundus were normal.
The two manpower samples (GM) on alternate days were negative.
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On the seventh day of evolution of his NFAR was found a non-painful necrotic ulcerated lesion in the hard palate, of which a biopsy was performed together with a biopsy of the right nasal mucosa.
Upon suspicion of IFI, a progressive decrease in prednisone was started and the otorhinolaryngology team was requested to perform a wide drainage of the paranasal sinuses.
Antifungal treatment was initiated with voriconazole and amphotericin B deoxycholate (AmB) 0.5 mg/kg/day, because the lipid formulation of AmB was not available at that time.
The histological study of the biopsy showed thick cenocytic hyphae, with angles at 90° in the sample of the perioral mucosa and maxillary bone, with negative culture.
With the histopathological diagnosis of mucomycosis antifungal therapy was adjusted: voriconazole was suspended and AmB in dispersion collar was started at a dose of 5 mg/kg/day.
Magnetic resonance imaging (MRI) of the brain ruled out CNS involvement at that time.
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A partial medial maxillectomy was performed endoscopically with resection of the inferior and middle turbinate and the medial wall of the right maxillary sinus.
The macroscopic description was "built of the lamina papyracea and discolored bone underlying the palate lesion".
The culture was positive for Rhizopus arizus (ex oryza).
Since then, AmBinto right dispersion a liposomal amberB was changed in the same dose. Due to bone involvement posaconazole max (20 mg/kg/day) was added and an extended resection was scheduled.
The biopsy showed fungal elements and the culture was positive for Rhizopus arizus.
A week later, the patient underwent a new surgery in which a surgical procedure was performed with resection of necrotic tissue and positive repair of a CSF fistula that became evident during the procedure. The biopsy etm.
The suspected CNS involvement increased the dose of liposomal AmB to 10 mg/kg/day.
Subsequently, it was maintained with associated antifungal treatment and surgical debridement and weekly surgical site packing change.
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After 45 days, the patient presented clinically an increase in right ventricular volume.
A CT scan of the brain showed involvement of the external table of the frontal bone.
A new surgical procedure was performed, and partial resection of the frontal bone and curettage were performed. A new rapid biopsy was positive for the same diagnosis.
The case was consulted with international experts and considering the infection with positive histological and microbiological samples after 45 days of antifungal treatment it was decided to associate caspoline with persistence 50 mg/m2/day liposomal AmB
She continued with weekly surgical gowns.
The patient was clinically stable, with imaging controls showing no changes and no evidence of microbiological relapse.
On day 106 of therapy the reconstruction of the maxilla and floor of the orbita on the right side was performed, with negative histological and microbiological samples.
Catechin was discontinued and maintained with daily liposomal amB.
At 148 days, chemotherapy cycles were restarted (myelogram without blasts) and after 12 surgical procedures and 170 days of antifungal treatment, AmB was suspended and treated.
It was agreed to use secondary prophylaxis during periods of neutropenia associated with chemotherapy with oral posaconazole (18 mg/kg/day monitoring plasma concentration) in form or with liposomal AmB in episodes of neutropenia outpatient setting.
