FATAL PNEUMONIA IN A PAEDIATRIC HSCT RECIPIENT

J Ratner*, R Barton

Abstract: 

An eight year old female with a history of β-thalassemia was admitted to Leeds General Infirmary to 
undergo a sibling donor HSCT. She began spiking fevers with rigours 2 days following transplantation 
and treated empirically with IV piperacillin/tazobactam (TZP). She was switched to meropenem after an 
extended spectrum beta-lactamase producing E.coli was isolated from peripheral blood cultures, which was 
TZP resistant. The source of the E. coli was thought to be from the gut, as she had abdominal pain and loose 
stools, however stool samples were negative for common enteric pathogens, including C. difficile. Five 
days after transplant, she developed pneumonia with a small pleural effusion which was too small to drain. 
Clarithromycin was added to cover pneumonia and Ambisome with stat Amikacin if required. Samples were 
sent for Mycoplasma, Legionella and a viral panel which were all negative and clarithromycin was stopped 
on day 7.
The patient continued to spike fevers and on day 11, a CT chest showed right upper-lobe consolidation and 
pulmonary thrombus with ground glass consolidation, and anticoagulants were started. Weekly Aspergillus 
antigen (galactomannan) screens were all negative. A bronchoscopy was performed and a soft grey mass of 
tissue was seen occluding the upper right bronchus. A bronchoalveolar lavage (BAL) was sent for bacterial 
and fungal culture, which grew coagulase-negative Staphylococci but no fungi.
Day 21, the neutrophil count began to return, however the patient was still spiking fevers and had increasing 
respiratory distress. CT and chest X-ray show a convex shape into a fissure affecting the whole right upper 
lobe, which was thought to be fungal and caspofungin was added in for 7 days. A sample was tested for β-D 
glucan, and was negative.
Day 29, the patient underwent a right upper lung resection, which was a difficult procedure with friable 
necrotic lung tissue showing mycelia on microscopy with calcaflour. Aspergillus antigen (serum) remained 
negative and samples from the lung biopsy were sent for culture, which was negative apart from a coagulase- 
negative Staphylococcus. She continued to have increasing oxygen requirements and worsening of chest 
radiograph, which now showed left sided lower lung consolidation with a small pleural effusion and patchy 
perihilar opacity of the right apex (which was removed). Voriconazole was added.
Day 31, CRP continued to increase and the patient was believed to have severe pulmonary aspergillosis 
and ambisome was stopped, whilst voriconazole was continued with caspofungin added in. Day 33, she 
had ongoing pulmonary haemorrhage and a serum sample was sent to Bristol for B-D glucan, which was 
positive. On day 35, the patient passed away from a sudden hypotensive and hypoxive episode.

2016

Full conference title: 

7th Advances Against Aspergillosis