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A 5-year-old Egyptian girl undergoing intensive antineoplastic chemotherapy for large T cell lymphoma, developed a necrotic lesion on the right wrist as well as pleural effusions and lung opacities on CT san, consistent with pulmonary and disseminated aspergillosis. A skin biopsy revealed numerous branching fungal hyphae consistent with aspergillosis; A. flavus grew on culture from a skin biopsy of tissue obtained from the left arm. She was treated with AmBisome (9mg/Kg) but the disease progressed and micafungin was added after 10 days. After A. flavus was grown from skin biopsy, the dose of micafungin was increased from 1.5-3.0 mg/Kg/d and given for 9 months daily. There was significant improvement in pulmonary lesion size over this time period and a needle biopsy of the lung was negative for hyphae.
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| Diagnosis:
Initially the diagnosis was proven cutaneous mould infection and probable acute disseminated and pulmonary aspergillosis, based on the skin biopsy result, but the subsequent positive culture from tissue resulted in a diagnosis of proven acute disseminated aspergillosis.
Response to antifungal therapy:
This child failed high dose AmBisome and then had some improvement with the addition of micafungin 1.5mg/Kg/d, but was still culture positive. The dose escalation to micafungin 3mg/Kg in combination with Ambisome resulted in a very slow response. Initially this would be classified as stable, but it gradually became a partial response.
Outcome:
A partial response to combination micafungin and AmBisome was observed. Excellent outcome. |