An immunocompetent, 14-year-old school boy with a history of pulmonary valve stenosis with biological valve prosthesis and valvuloplasty, who had tricuspid valve electrodes due to an atrio-ventricular block.
Recently, a new biological valve replacement and tricuspid valve plasty had been performed.
Five months later, the patient consulted for four days of painful pre-stomal volume increase without fever.
At that time, the complete blood count had leukocytes of 14,800/mm3 and CRP of 40 mg/L. An ultrasound of blade tissues showed an increase in the thickness and echogenicity of the subcutaneous cellular tissue estimated at 10 ml.
The patient was operated on with the diagnosis of mediastinitis and after obtaining samples for culture by premedication antibiotic treatment was initiated empirically with vancomycin and i.v. meropenem.
Early surgical drainage, curettage and partial extraction of epicardial lead were performed.
During surgery, compromise of the sternum was evident, confirming a mild sternum with bone compromise and infection of the jawbone.
Blood cultures, collection and tissue current cultures had no bacterial development.
PCR for Mycobacterium spp. and Staphylococcus aureus resistant (MRSA) were performed from the collection and were negative.
The patient was placed in good general condition, afflicted.
Antimicrobial treatment was adjusted to vancomycin, cefoxime and amikacin, completing 28 days in total.
Outpatients completed two more weeks with oral cefpodoxime and clindamycin.
A non-contrast-enhanced CT scan showed post-surgical changes, a chronic osteomyelitis is low, without residual stenosis.
One month later she consulted for pain in the right subcostal region, without fever.
An X-ray of the chest revealed a non-specific inflammatory process, and ultrasound showed a soft tissue compromise of the subcutaneous cellular sternum with persistent subcutaneous tissue and an appendix in the depth of the xiphoid tissue.
The treating team decided to observe the evolution.
Subsequently, a chest CT scan was performed, which showed the presence of seizures and a lytic lesion of the lower end of the sternum.
It was decided to restart antimicrobial treatment with oral clindamycin and ciprofloxacin for four weeks.
1.
Approximately one year after valve surgery, the patient developed a new increase in painful volume in the area.
An ultrasound showed a heterogeneous, avascular, subcutaneous collection of contents and a subxiphoid retro collection.
A sample was obtained from the collection by puncture inoculated with hemofilament for aerobics, anaerobics and mycobacteria, Gram stain and Gram stain.
The patient underwent surgical intervention for removal of cables and mediastinal aseo, where samples were obtained for cables and tissue cultures.
Tissue samples were placed in plates and agar tubes Sabudududududa-anfenicol 2 (SGC2), Biomerieux, which were incubated at room temperature at 35°C and gentamicin was administered at room temperature.
After surgery, empirical treatment with clindamycin and cefoxime iv was started.
The hemocultive vial of the sample collection was positive at 54 hours of voiding.
In Gram stain hyphae were observed and amphotericin B deoxycholate was initiated.
After 72 h of sowing the Saboureaud agar plates, the development of green flat, cotton-yellow colonies on the surface and colorless on the reverse was observed.
On microscopic observation carried out with lactophenol blue, partitioned hyaline hyphae were found, with presence of asperid heads in form of smooth upper thirds with smooth and regular colorless conidiophores.
With these characteristics, A. fumigatus was confirmed.
This result was consistent with those isolates inoculated with hemocultives.
After identification of the species, the antibacterial agents were definitively suspended and antifungal treatment was adjusted to voriconazole 200 mg every 12 h.
The patient was placed in good condition with a post-surgical chest CT scan with small tapes: peri- and multiple sclerosis.
After one week, the patient was discharged with voriconazole at the same dose.
During outpatient follow-up, the patient remained clinically well, with adequate voriconazole plasma levels.
The imaging control showed a slow regression of residual lesions.
After 10 months of treatment with voriconazole, with a chest CT scan showing a smaller size than the previous studies, antifungals were suspended and discharged 21 months after surgery for recurrence
