case_images: PMC11424411_01
case_images: (A) Plain CT scan image of the left lung on day 2. (B) An emergency CT scan image obtained after 12 days indicates patchy ground-glass shadows in the dorsal segment of the left lower lobe. (C) An enhanced CT image obtained after 22 days shows a reverse halo sign in the left lung. (D) Enhanced CT image obtained on day 30 presents the left lung infarction. (E) Surgical photos of lesions showing the left lower lobe infarction.
case_images: fped-12-1453059-g001.jpg
case_images: PMC11424411_01_fped-12-1453059-g001.jpg
case_images: F1
case_images: All pathogen tests including epstein-barr virus virus, cytomegalo virus, hepatitis virus, etc.,are negative, and no obvious infectious lesions are found in the CT scans of the head and chest (Figure 1A) and in the abdominal ultrasound. These persistent clinical symptoms and rapid progression of pulmonary infection as evident in the pulmonary CT (indicated an area of ground-glass opacity surrounded by consolidation on day 12 (Figure 1B), led to the diagnosis of a mixed bacterial and fungal infection. In the chest CT on day 22, the left lung revealed a consolidation enlargement with central ground-glass shadows, recognized as the reverse halo sign (RHS) (Figure 1C), indicative of a characteristic feature of PM. Notably, the lung CT suggested the presence of a left lower lobe infarction on day 30 (Figure 1D). Therefore, as a timely intervention, emergency surgery was performed, which caused a left lower lobe infarction during the procedure (Figure 1E), confirming the initial suspicion.
case_images: (A) Core body temperature curves. (B) The treatment timeline. VSAA, very severe aplastic anemia; CT, computed tomography; VP - 16, etoposide; mNGS, metagenomic next-generation sequencing.
case_images: fped-12-1453059-g002.jpg
case_images: PMC11424411_01_fped-12-1453059-g002.jpg
case_images: F2
case_images: Despite aggressive anti-infection therapy (i.e., meropenem, teicoplanin, linezolid, levofloxacin, and imipenem/cystatin) (Figure 2) for nearly two weeks, there was persistent fever, intermittent hemoptysis, and chest wall pain. Although the antifungal therapy (i.e., amphotericin B liposome, caspofungin, and isavuconazole) (Figure 2) was started, there was still a persistent fever, severe agranulocytosis, and uncontrolled pulmonary infection. Based on adequate anti-infective treatment, methylprednisolone, etoposide, ruxolitinib, and plasma exchange were administered to control inflammatory response (Figure 2).