CT Scan after 130 days of treatment

CT scan day 130
 

This 30 yr old man with CML underwent a matched BMT from an unrelated donor. Immunosuppressive drugs plus initial antifungal therapy of fluconazole was given followed 2 weeks later with Lip AmB. Patient had persistent coughs and fevers. 
On day63 Caspofungin was given but changed to Voriconazole 200 bd on day96 as a result of worsening LFTs the dose was reduced to 200/d. On day96 progressive changes were seen on CT. On day100 concern re progressive to invasive Aspergillosis /Other mould infections? increased Voriconazole to 400/d.
Patient showed ongoing symptoms of GVHD and continued on methotrexate and cyclosporin. 
Poor LFTs at day 110 lead to change of therapy to Lip. AmB with the aim of reintroducing Voriconazole. On day 108 a bronchoscopy was performed -but no diagnosis could be reached.
Day116 repeat colonoscopy/gastroscopy showed severe architectural damage, active GVHD Ileal and colon biopsy positive for yeast spp.
Day 139 Bronchoscopy – purulent secretions in lingual and LLL, BAL fungal culture negative, PCR was + Aspergillus spp.Day 155 treatment was switched to caspofungin due to patient concern. During the next 40 days the patient was given caspofungin,voriconazole, then caspofungin followed by itraconazole which was not tolerated. On day 226 the patient died.