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.
Mr RM is 80 and an ex-coal miner.He developed pneumoconiosis from exposure to coal dust. He also developed rheumatoid arthritis and the combination of this disease and pneumoconiosis is called Caplan’s syndrome.
His chest Xray in early 2015 shows extensive bilateral pulmonary shadowing with solid looking nodules superimposed on abnormal lung fields, contraction of his left lung with an elevated diaphragm and a large left upper lobe aspergilloma, displaying a classic air crescent. His CT scan from mid 2014 demonstrates a large aspergilloma in a cavity on the left, with marked pleural thickening around it, which is partially ‘calcified’ towards its base. Inferiorly on other images,remarkable pleural thickening and fibrotic irregular and spiculated nodules are seen, most partially calcified.
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